Overachievers on a plane

"If there is a physician on the plane, please press your call light!"

The vast majority of doctors who have flown on airplanes have heard this, and most of us are willing, if not entirely eager, to respond. What follows is usually a far from ideal encounter with inadequate information, too much noise, a cramped space to work in and little knowledge of what is expected or even possible.

My experiences (I think there have been 3) were people who had become dizzy or had passed out. One of them was pretty frail, but none required that we land before our destination airport. What I learned was that:

1. More than one physician usually responds to these calls. As a general internist, I'm usually the most appropriate person to evaluate the patient (winning out over ophthalmologists, dermatologists and obstetricians.)

2. The flight attendants are very grateful, bring me an extra glass of juice and promise some kind of compensation from the airline which may or may not materialize.

3. It's really pretty challenging to do it right, and I end up spending weeks thinking about the ways I could have done it better.

Since the last experience, I have looked up what is in an airplane medical kit. There is a stethoscope, a blood pressure cuff, an IV and some fluid, some IV glucose for hypoglycemic patients, an asthma inhaler, some non-aspirin pain reliever and some actual aspirin for suspected heart attacks, some medication for severe allergic reactions and some stuff that might be useful in a cardiac arrest. All planes must carry an automatic external defibrillator, which is as it should be. There is nothing particularly useful for nausea, severe pain or anxiety.

There is no protocol that I was aware of regarding what needed to be done. There was no obvious way to communicate with the doctor who would take care of that patient after the event in the plane about what had actually happened. There was no way to find out whether the patient did OK after he or she got home that I could use to help guide my next experience.

I just recently had a discussion with a couple of other physician friends (overachievers I guess) about what we do and how to prepare for the inevitable "doctor on a plane" scenario. Despite not knowing whether we had made the right decisions (other than that our patients remained alive and presumably vertical at the end of the flight) we all wanted to do better. We had been good Samaritans, but we wanted to be very good Samaritans.

The first thing we discussed were our tools and tech. My kit includes a small ultrasound (if I'm going somewhere medical, which I usually am), a tiny two lead electrocardiogram which works with my iPhone and fits easily in my purse, my lightweight stethoscope (which actually works, unlike the ones on the plane) and a not-so-basic first aid kit with medication for various random diseases. My friend carries an oximeter (measures blood oxygen level) as well. I always have a downloaded copy of UpToDate, a constantly updated disease and treatment encyclopedia, on my phone.

I try to find out my patient's story, including medical history and what they think is going on. I provide as much compassion and reassurance as such a cramped space will allow. Still. I think I could do better.

The main problem is not that I didn't think to bring the oximeter, but the fact that the process is bad. Airlines know that medical emergencies happen when they are aloft. They should be less random about how they respond. According to Bloomberg, many airlines contract with MedAire, a remotely available medical service that serves aviation and yachts and other situations that require medical advice at unscheduled times. Apparently they must only use this service when they think they need it, because none of my events seemed to use any remote support. But it is available. Why, as the doctor responding to the emergency, did I not know that they were available?

A person who gets sick on a plane is in a bad situation. He or she is often old, sometimes alone and always vulnerable. It is frightening and embarrassing be sick on a plane. Airlines charge lots of money for their services and are at risk for expensive diversions and crushing damage to their reputation if these scenarios go poorly. They should try to get this right.

I would propose:

1. Ask people at the time they schedule a flight whether they are a physician and whether they would be interested in being called upon in an emergency.

2. If we say yes, get a copy of our medical license. If my relative got sick on a plane, it would be awfully nice to know that the physician who responded to the event was actually a physician or an otherwise qualified medical professional.

3. Give us a little information to read on the process, including what is expected of us, what kind of support exists, what is in the medical kit...

4. Have the flight attendants take some kind of medical history from the patient or relatives if possible and enter that data into a simple electronic form. Make it possible for the doctor to enter some information about what happened. Send that to the patient and or his or her primary care provider.

5. Compensate us in some (maybe small) way for volunteering, since it is not necessarily an easy thing to be on call on a plane. Compensate us more generously if we provide a service. Let us know what the compensation will be.

6. Tread gently around Good Samaritan laws so we won't be exposed to liability. From what I read, it looks like preparing for this kind of thing and even being compensated for it wouldn't create a problem.

This isn't just overachieving. Doctors actually want to do a good job whenever we take care of someone. When we respond to the inevitable "is there a doctor on the plane?" we are agreeing to participate in a system that makes it difficult to provide adequate care. That would be acceptable if we were in a refugee camp or disaster situation, but airlines could and should be held to a higher standard..

Dang. Just have to rant about some really expensive drugs: Lucemyra, Trelegy Ellipta and Andexxa.

The price of new drugs just seems to go up. I've stopped being excited about innovative pharmaceuticals that target various hard to treat diseases and conditions, simply because they cost so horribly much. Each of these new developments looks like a classic philosophical dilemma. Do I pull the lever that makes the trolley kill one person instead of 5 or do I save the one and allow the trolley to kill 5? Do I prescribe the new drug that potentially helps my patient but may destine a whole population to lousy health care by making the overall budget unsupportable?

When I was in residency in the 1980's medication that cost a dollar a pill was crazy expensive. Inflation doubles that plus a little more, so think $2.25 and pill in 2018 money. But today's expensive medication costs 10-20 dollars a pill. Or $1000 a pill for the drug to cure hepatitis C. Or, in the case of a now pretty commonly used drug for advanced cancer, $150,000 a year. This is real money. On the lower end, it costs as much as all of one's food. At the higher end, it is enough to live like a rich person. If we insist that everyone have access to some of these new drugs we admit that we will never be able to offer universal health care. It would eat up all of the money we have.

Here are the new, latest and greatest drugs announced in The Medical Letter of Drugs and Therapeutics, a publication published by a non-profit not aligned with any pharmaceutical companies.

1. Lofexidine (Lucemyra) for opioid withdrawal: this is a central alpha receptor agonist, similar to the drug clonidine, which has been available and successfully used for the physical symptoms associated with ceasing to take opioid drugs when one is addicted. It reduces the anxiety, sweating, irritability and diarrhea that characterize withdrawal. It costs $1738.00 for a week supply. It is no more effective than clonidine which costs $1 for a week, though it does cause less reduction in blood pressure. The drug of choice for this situation is buprenorphine which costs $23 for a week.

2. Trelegy Ellipta: inhalers for asthma have been prohibitively expensive for years. People with airway obstruction, classic asthma with wheezing, shortness of breath and cough, usually require inhaled medication to open up the small airways in the lungs and to reduce mucus and inflammation. Originally the only drug for this was epinephrine which eased breathing when injected, taken orally or inhaled, but also sped up the heart and caused the shakiness associated with adrenaline release. Newer drugs worked on the inflammatory response, reduced the cardiac side effects and were longer acting. Inhalers cost less than $20 for a month supply when I graduated from medical school. Now some of the common brand name inhalers, combinations of long acting bronchodilator and a corticosteroid for inflammation, cost $300-$400. Now Trelegy Ellipta has been introduced which costs $530.00 for a month's supply. It includes 3 drugs rather than 2, and if one were to buy those three types of drugs as individual inhalers they would cost more than that. People mostly use a drug like this every day forever, at a cost of $6360 per year. Many of these drugs are not available as a generic, but even generics can be costly. Some of the generic combination inhalers cost less than $100 a month, but different patients respond differently and some have no luck at all with certain drugs or combinations and will end up on branded products.

3. Andexxa (andexanet alpha) will rapidly reverse certain anticoagulants ("blood thinners"). A few years ago the most commonly used anticoagulant, warfarin (coumadin), got some competition. A new drug was approved that reduced clotting by a slightly different mechanism and did not require regular blood tests to monitor it. Now there are at least 3 such drugs commonly used for patients who have a high risk of blood clots. They are considerably more expensive but also a bit safer and quite a bit more convenient. Unlike warfarin, however, which can be reversed by vitamin K or fresh frozen plasma, the new anticoagulants did not have an effective reversal agent. So if a patient on one of these new blood thinners came in having injured themselves, with uncontrolled bleeding, it was very difficult to stop the bleeding. We did discover that prothrombin complex (Kcentra is the brand name) worked pretty well. The hitch was that it cost about $5000 for the usual injection. We still used it, but it definitely put a dent in pharmacy budgets in hospitals. Andexxa was specifically developed to reverse two of these newer anticoagulants, apixaban and rivaroxaban. It can be dosed low or high, depending on the dose of the anticoagulant. One high dose treatment costs...wait for it...think high...YES. $49,500.

Costs of this magnitude are hard to put in context. I have read that there are about 750,000 people on the newer anticoagulants. If one in a hundred of them had a bleeding episode in a year which was treated with Andexxa, that would be nearly 400 million dollars. 400 million dollars is enough money to buy a year's supply of a nice cheap generic blood pressure pill for 10 million people to help prevent the atrial fibrillation which eventually leads to prescription of the anticoagulant. Or enough money to pay for a week's vacation to Hawaii for 10,000 people, which is mostly irrelevant.

What makes me sad here is that these new drugs are being pushed out of the pharmaceutical pipeline and, although they have the potential to reduce misery if used for the conditions they can treat, they will bankrupt either real people or health care budgets or both. The folks who could benefit from them will perhaps achieve better health only to be crushed by debt or unable to afford health insurance.

Something could be done to fix this.

Pharmaceutical companies are motivated to create drugs whose high prices and popularity will result in profits. We can, however, fund drug development in a different way. If academic labs developed drugs through grants from the National Institutes of Health or other government agencies, their costs would not need to be made up by sky high drug prices. In fact, since the government pays the vast majority of health care costs in one way or another, the payoff for these grants for drug development would be through lower pharmacy costs and also improved health and productivity. This kind of payment would favor affordability and efficacy, not just expensive drugs that add very little incremental benefit for patients.

For now, new drugs come from pharmaceutical companies and are priced beyond what a conscientious health care system can pay. Still, these drugs will be advertised and prescribed and health care costs will go up and medical debt will destroy lives. It's really hard to get excited about this most recent batch of wonder drugs.

How did American healthcare get so expensive? Perhaps it was Ronald Reagan's presidency.

The New York Times has pointed out a very interesting coincidence. It was during the presidency of Ronald Reagan that health costs and outcomes began to diverge from the rest of high income countries with which we compare ourselves.

In an article by Austin Frakt, a healthcare economist, physicist and mathematician, he points out that America began to abandon healthcare cost controls, except for Medicare, when Ronald Reagan took the helm from Jimmy Carter, who had steadfastly backed limiting public and private healthcare spending. Deregulation of many institutions followed. Regulation of industries related to health were rolled back and new regulations which helped control spending in Europe were not introduced.

In the early 1980's insurance companies began to change the way they paid hospitals for their services, introducing "DRG's (diagnosis related groups). Hospitals responded to this change in payment methods, being paid according to diagnosis rather than time or intensity of treatment, by increasing their size and leverage and mobilizing other cost centers to bolster their profits and economic viability. To be fair to hospitals, this was a difficult time for them and many failed. Nevertheless, in a successful change in strategy, they did begin eating up more healthcare dollars.

Other developments that came with this conservative sea change included support for medical spending to the exclusion of social spending and the success of big drug companies in marketing their more expensive products to consumers.

These are some very compelling associations and definitely worth exploring further. In addition to helping explain our high healthcare costs,  these observations suggest some remedies that might gain traction in the post-Trump era. The article is short and sweet and I encourage you to read it. I am looking forward to a more detailed look at what actually happened from this or other authors with suggestions for concrete changes in our future direction.

A monoclonal antibody to prevent migraine!

This last week a monoclonal antibody injection for migraine was released, with fanfare and great hopes of becoming a commercial success. Amgen developed Aimovig (erenumab) and published its findings in the New England Journal of Medicine last November. It is an injection that targets calcitonin gene-related protein (CGRP), a chemical released in the brain during migraine which dilates blood vessels. The monoclonal antibody inactivates this protein for a long time, on the order of one and a half months.

Migraine is often involves head pain, nausea, weird neurological symptoms including vision loss and even stroke symptoms. The combination of symptoms is frequently disabling and "migraineurs" suffer not only from their nausea and headache, but also from large financial burdens associated with the condition, on average around $6000/year for chronic migraine sufferers. The economy loses over $13 billion in lost workdays. Over 44 million people in the US have migraines, though this probably underestimates the numbers since many never come to medical attention. Migraine is a worldwide problem. In a rural area in Haiti where I have seen patients, the most common complaint was "tet fe mal, vant fe mal" meaning "my head and my stomach are bad." I was confused because of how nearly universal the complaint was. In retrospect they were describing migraine. I come from a family of migraineurs and can attest to how chronic and episodic migraine affects the rest of us: children with migraine vomiting their Saturday French toast, a mother with migraine spending what seemed like half my childhood in a darkened bedroom, a partner with alarming neurological symptoms. It's enough to give those of us without headaches headaches.

Theories of what causes migraines have evolved over the years and presently I understand that the phenomenon is felt to be a "spreading depression" of brain electrical activity, resulting in hypersensitivity to normal processes including the pulsating of blood vessels. Migraine is hereditary and common, and includes some annoying but tolerable symptoms such as caffeine withdrawal headache, carsickness and ice cream headaches. It can also be a disablingly horrible, usually pulsating, headache with nausea and vomiting, light and sound sensitivity, sometimes preceded by sparkles or blind spots that move across the visual field. It can be brought on by a change in routine, certain foods or drinks, menses and stresses. Home remedies bring mixed results: caffeine helps but can perpetuate headache, as can normal analgesics. Anti-inflammatories including aspirin can be very effective, but daily use can induce migraine and can cause ulcers and intestinal bleeding. Herbal remedies such as feverfew have gained attention from the medical community in the last few years but are not very effective for most people. "Triptans" (including sumatriptan, the first in the class) which can be taken by pill, shot or nasal inhalation, can be quite effective, but not universally so, and are still costly. Many patients, in the throes of a migraine they can't control at home, end up in emergency rooms for intravenous treatments which can leave them or their insurance companies with multi-thousand dollar bills.

Preventing migraines by the use of medication has been an effective approach for decades. When lifestyle approaches such as regular sleep and meal schedules, exercise and management of specific triggers is not effective, drugs in the beta blocker, antidepressant and anticonvulsant categories can be tried. Not all migraine prone people need to take medication to prevent headaches, but if the headaches are severe or frequent or associated with severe neurological symptoms, this is a good approach. One of the earliest drugs used for migraine prevention was methysergide, an ergotamine derivative, which was very effective but caused a frequently fatal side effect of scarring of the internal organs in one in 5000 patients. It is rarely used now, and is not available in the US. Several beta blockers, also used to treat high blood pressure, are effective, with the main side effects being change in the heartrate and feeling cold in the hands or feet. With prolonged use they can lead to weight gain and increase the risk of diabetes. Amitryptilene, an older tricyclic antidepressant, can be effective in migraine and other pain syndromes, but does lead to weight gain and can cause intolerable sleepiness. Valproic acid, a drug originally for epilepsy, can be quite effective, but also causes weight gain, can upset the stomach and cause lethargy. Topiramate, a more recently developed drug for epilepsy, has been remarkably effective, without causing weight gain. In fact it can help with weight loss. It can cause sleepiness and brain fog however. I used to say that these drugs made you fat, stupid and poor, but they are all now generic, so with the exception of topiramate, just fat and stupid. For those who get these side effects, the trade-offs are often unacceptable.

Enter, now, the monoclonal antibodies. There are four of them, with the unpronouncable names of eptinezumab, erenumab, fremanezumab and galcanezumab. Erenumab is the first to have been approved by the FDA. It is given as a subcutaneous injection once a month and, in the study reported in the New England Journal of Medicine last year, at the higher dose tested it reduced the number of headache days by about 50%. The study lasted 6 months and the primary side effect was upper respiratory and sinus infections. There was an excellent editorial in the JAMA (Journal of the AMA) by Elizabeth Loder MD and Matthew Robbins MD which mentions some other concerning information. In clinical trials of fremanezumab and erenumab there have been 3 deaths: one due to suicide, one to chronic obstructive lung disease and another to an arteriosclerotic event. These were probably people thought to be relatively healthy, or they wouldn't have been included in a clinical trial. Also, although these causes of death seem to be far removed from migraine prevention, the target of this monoclonal antibody, the protein CGRP, could definitely have something to do with any of the three. Trials of these drugs have been pretty short, and we don't really know whether there are any long term safety problems. This is a real concern, since migraine is often a lifelong disease that can start in childhood.

The cost of these drugs is a real concern as well. Erenumab has been priced below what was initially predicted, out of concern that a higher price point would invoke the wrath of everyone who is already angry about ridiculous drug costs. Erenumab is considered "affordable" at an estimated cost of $6900 per year. Almost $20 per day. Wow. I sure wouldn't want to deprive a fellow human of a chance to be relieved of pain, but if even 1% of migraine sufferers use this medication for a year, it will add tens of millions of dollars to the healthcare budget. In comparison, a drug like topiramate costs less than a dollar a day and is about as effective. Methysergide, when it was studied, was even more effective.

The bottom line on all of this as I see it: Migraines are terrible and common and the treatments are far from perfect. Prevention is important and the drugs for this are also far from perfect. There is a new option out there which is wickedly expensive and has unknown long term side effects but may work where other drugs do not. We will all pay for it (and its yet to be released cousins) via higher taxes and insurance costs.

How the best of care can be terrible without bedside ultrasound

I just read a "Clinical Problem Solving" case from the New England Journal of Medicine (NEJM). It was entitled Stream of Consciousness and it told the story of a 65 year old man who was a patient at the Brigham and Women's Hospital of Harvard Medical School, arguably one of the finest medical institutions in the world.

These cases are presented in single paragraphs to a clinical expert physician who then comments about his or her thought processes and discusses how he or she would have handled the situation. In this narrative the patient presented to a different hospital in New England with kidney failure and a gradual onset of confusion in the setting of very high blood pressure. He was then transferred to the Brigham and Women's Hospital for further evaluation and treatment. He had lab tests of all color and stripe along with MRI and CT scans of his brain which showed some disconcerting spots. He had a lumbar puncture and his high blood pressure was treated. Eventually, after 2 or 3 days in the hospital (I can't tell from the narrative), an ultrasound was done which showed that his bladder had not been emptying properly, which had caused the kidney failure and probably the high blood pressure. A foley catheter was placed which drained nearly 3 liters(!) of urine after which his blood pressure was much more easily controlled.

The exciting diagnosis was Posterior Reversible Encephalopathic Syndrome (PRES) which was first described in a case series in 1996. It is closely related to eclampsia, a condition of women in labor or directly following labor in which the is injured by high blood pressure leading to seizures and sometimes death. The cause is thought to be leakiness of the blood vessels in the brain related to high blood pressure. It is very important to recognize PRES because prompt treatment to lower the blood pressure can prevent long term brain damage.

This guy had the best of treatment by the best of doctors, but what he really needed was a bedside ultrasound at the first hospital or on arrival at the Brigham. People who read this blog will have noticed that I am a strong proponent (nerd perhaps) of ultrasound performed by a treating physician as part of a physical exam in just about everyone with a significant medical concern. If he had a bedside ultrasound the doctor performing it would have seen that the collecting systems in his kidneys were dilated and that the cause was a massively over-full bladder, likely due to an enlarged prostate. The bladder would have been drained immediately, resulting in correction of his blood pressure and improvement in his kidney function. He might not have needed to be transferred to the larger hospital at all.

Perhaps his physicians at the community hospital did not know how to perform an ultrasound. Still, he would have benefited mightily from prompt point of care ultrasound once he arrived at the Brigham. Head scratching about the cause of his kidney failure might have been curtailed. Blood pressure control would have been more rapidly achieved, benefiting his spotty brain. His very complete and likely very costly evaluation might have been briefer and less expensive. Physicians might have been able to discharge him to home more quickly.

The impact of bedside ultrasound could have been even more profound had it been done even earlier in his course. This fellow's problem emptying his bladder did not happen all of a sudden 3 weeks before he came to the hospital. It is likely that he had mentioned to his primary care doctor some slowness passing urine or a feeling that he hadn't emptied completely. If that physician had performed an ultrasound of the bladder in the office he would have seen that it wasn't emptying properly and would have initiated some kind of treatment before it got to be the size of a large honeydew melon. It is possible, even likely, that this whole near-tragedy could have been prevented.

Bedside ultrasound is not yet the standard of care among internal medicine physicians. It should be, and in the fullness of time, it probably will be.

Comparing the US with other high income countries: how do we pay so much for healthcare?

Healthcare costs in the US are significantly greater than in any other developed country and for this we have a shorter life expectancy than they. We also develop cutting edge technologies and miracle cures and are world leaders in medical research. Just how do we compare with other economically advantaged nations?

In a Special Communication article in the JAMA (Journal of the American Medical Association) this week, Harvard researchers Irene Papanicolas, Liana Woskie and Ashish K. Jha analyzed data from Japan, Australia, Switzerland, Germany, France, the Netherlands, the United Kingdom, Canada, Sweden and Denmark about healthcare and social spending as well as outcomes. It is a huge amount of data gleaned from diverse sources and the authors have presented it beautifully. I will only comment on it and can't possibly do it justice. Still, there are several really interesting facts to point out, so I will dig in.

In US dollars, our spending per person per year is higher than any other country in this group. We spend the equivalent of $9403 in public and private money on healthcare for each of us. Our closest competitor is Sweden at $6808 and the UK comes in at $3377, in last place. This is 17.8% of our gross domestic product. Sweden spends 11.9% of its GDP and the UK 9.7%. How did we get so expensive?

First, the researchers wanted to test the assertion that American healthcare is expensive because people use too much of it. That is a complex question, but generally speaking the answer is no. We place right in the middle of the pack in hospitalizations for heart attacks, pneumonia, lung disease and mental illness. Germany is the leader there. We do get more cardiac bypasses and angioplasties, far more knee replacements and a few more caesarian sections and CT scans. We don't get more hip replacements. We have more outpatient visits but not more hospitalizations. This is not the key issue.

They also wanted to test the hypothesis that we spend more in healthcare because we don't allocate as much on "social spending" which is defined as benefits to people who are in bad circumstances. We are neither the highest nor the lowest in this category, though we are on the low end, near Australia and Canada. I'm not at all sure that supporting people once they are in trouble should be the definition of "social spending." It seems to me that money spent on education or a healthy environment, walkable cities, good jobs and opportunities for vibrant aging would be more likely to affect healthcare spending than social welfare. Perhaps spending on those is difficult or impossible to measure.

Health expenditures are quite different in different countries. The US, for instance, spends much more than the other countries on administration, think billing clerks and insurance companies. We spend 8% of our budget on this stuff. Surely we could follow the examples of Japan, France, Denmark, Sweden and the UK, all of whom keep these costs to under 3%. That would be an enormous amount of money saved without jeopardizing vital services.

We are neither high nor low in our spending on preventive healthcare, though I think they are doing different prevention than we are.

We have fewer primary care physicians compared to specialists than France and Canada, but not than the rest of the countries, which surprised me.

We spend more money on prescription drugs than any other country, equivalent to $1443 per person, twice as much as the average for all of the countries combined. We lead the pack in use of generics, but apparently that doesn't matter because even our generics are expensive.

There is a measurement called "horizontal inequality" which I hadn't heard of before. It is the likelihood of seeing a doctor in the last 12 months and whether that correlates strongly with wealth. In the US it does. Wealthy people see doctors pretty often and poorer ones do not. We are significantly worse in this regard than in Canada, France, Germany or the UK. The other countries did not have data to evaluate that. The reason for this is pretty clear: in every other country healthcare is available at a cost that is affordable, either by private insurance or government coverage, to 99-100% of the population. We are at 90%.

We do not look very stellar when it comes to certain outcomes. Our maternal mortality is 3 times as high as the next highest country, the UK. Our infant mortality is also higher, though not as egregiously so. Our life expectancy is 3 years shorter than the average of all of these countries, at 78.8 years. We are among the best, however, in mortality from strokes and heart attacks, and it is easier to get in to see a primary care doctor or specialist in the US than most other places.

We are more obese (70% obese or overweight), but not more likely to smoke or drink to excess. Our doctors are paid considerably more, but there are fewer of them per number of patients, so that apparently balances out.

Americans are the people least happy with their healthcare system. 19% feel the system works well and 23% believe it needs to be completely rebuilt. But none of these privileged countries to which we are compared is doing a great job, in the view of their citizens. Germans are happiest, but only 60% of them think their system works well. Canada pleases only 35% of its people. Worldwide, it seems like there may be quite a bit of room for improvement.

The authors of this study conclude that the costs of pharmaceuticals, devices, labor and administration are the main drivers of higher healthcare costs in the US. That is a good starting place for explaining how our system got to be so much more expensive than other countries. I'm curious, though, about how other countries develop good systems, what processes they have that are not good, either inefficient or providing poor care, and how they have evolved, since that could be helpful in moving all of us in the right direction. The United States continues to be one of the most productive innovators in the world, sometimes jettisoning expensive and useless routines and replacing them with ones that serve us better. Our innovations often drive savings and better outcomes in other countries. We need to learn from them as well.

This article is a good way to look at "how is American healthcare so expensive?" The why of it is more complex. Several commentary articles accompany this one, with delightfully different conclusions. It's a fascinating subject. I'll keep looking into it and write when I find the answer.

Drug costs and copays

Drug costs in the US are higher than in in any other industrialized country in the world. Our cost for an insulin glargine (long acting insulin) pen is $76.80 and in Canada, so very few miles away, it costs $19.60. The latter price is reasonable. The former price can make the difference between being able to afford a life saving drug and dying. It is illegal, however, for a US citizen to buy his or her insulin, or any other drug available in the US, from another country.

Costs of pharmaceuticals in other countries are usually regulated by the government. Not so in the US. This is due to the lobbying power of US pharmaceutical companies. Because US citizens pay more for our drugs, we do have earlier access to newly released products than other countries if we can afford them. Our deep pockets help make new drug development attractive to drug companies. For people whose lives depend on the development of a new drug, this is very important. For the vast majority of patients, however, high drug costs can be at least burdensome and often crushing.

Healthcare costs were a major subject in the most recent issue of the JAMA (Journal of the American Medical Association.) Pharmaceutical costs were discussed in a brief article from the Medical Letter on Drugs and Therapeutics.

Not all drugs in the US are expensive, however. Such staples as lisinopril for high blood pressure and simvastatin for elevated cholesterol cost only a few dollars per month. When we go to the pharmacy and pick up these prescriptions, and the pharmacy submits the claim to our insurance companies, we pay a few dollars as a copay and go away generally happy. The low price we pay, or so we think, is thanks to the fact that our insurance is helping us out.

Tucked in the back of the issue is a letter by four health policy PhD's (Karen Van Nuys et. al.) from the University of Southern California. They researched overpayments at pharmacies by patients for drugs whose actual costs to the insurance companies is lower than what the patient pays. That's right. For some drugs, mostly the less expensive generic ones, the patient pays the pharmacy more than the pharmacy charges the insurance company and the insurance company pockets the difference. In some of these cases, the contract the insurance company has with the pharmacist prohibits the pharmacist from telling the patient about this.

I find this infuriating primarily for the lie involved. I know that insurance companies are primarily interested in making a profit, and so they do. If they couldn't turn a profit, they would go out of business. That's how it works. But it bothers me that they make patients believe that they are helping them pay for medication when they aren't. Each patient usually only loses a few dollars on the prescription for which they are overcharged (except a few on the list they published, including the nasal spray fluticasone and the antibiotic amoxicillin/clavulanate, for which the overpayment was $12 to nearly $20 per prescription), but the insurance company makes a bundle on the huge number of transactions.

Drug costs are crippling to many people, especially those with chronic diseases. Insurance companies should at least be honest about their contribution to this problem.