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Prairie Doc Perspective for the Week of August, 2023
“Challenges facing US health care” By Tom Dean, MD Assuring effective health care to a population is a challenge for every society. As care options become more complex – and expensive – the challenges increase. In the US both the organization and the financing of health care are perennial issues in public discussions, political campaigns and among social policy researchers. Basically there are two distinct but intimately related concerns – providing access to care and paying for that care. There is widespread agreement that when folks are sick or injured they should receive appropriate care. Disagreements emerge, however, in deciding how to pay for that care. I believe it is instructive to look at the experience of other wealthy developed countries that have similar challenges. Doing so is actually quite sobering. Using data from the Commonwealth Fund, a respected independent research organization, we can compare US experience with that of Sweden, Australia, France and Canada. These countries differ significantly in aspects of culture and geography. They do, however, all guarantee health care to 100% of their population. They spend approximately $5000 per capita (range $5447 to $4965). In the US the expenditure is $10,586 per capita and approximately 10% of the US population have no form of health care coverage. Life expectancy in each these countries exceeds that of the US - 82 yrs. (range 82.0 to 82.6) compared to a US average of 78 yrs. Recently the US life expectancy has actually gone down. An area of particular concern in the US is maternal mortality – death related to child birth. In a modern society birthing mothers should not be dying. Nonetheless, maternal mortality in the US is higher than in any of these countries and it has gotten worse. US rates currently are 3X higher than Canada, 4X higher than the UK and 10X higher than Australia. In some areas US performance is quite good. Outcomes In the treatment acute myocardial infarction (heart attack), stroke and some types of cancer in the US are significantly better than in comparable countries. A troubling feature of care in the US is that all too often there is inadequate coordination between different parts of the care system. This leads to inefficiency and often poorer results. To further complicate the situation, patients, fearing high costs, often put off seeking care. Delayed care increases the risk of both poor outcomes and increased expenditures over the long run. A contributor to high costs that has gotten relatively little attention is the complexity of US administrative and billing procedures. Providers (physicians, hospitals, therapists, etc.) have to document – and often justify - every service provided. Commonwealth Fund estimates are that administrative outlays account for as much as 1/3 of all health care expenditures. No other comparable country comes close to that rate. There are differences between countries in patient populations, utilization of technology, etc. Researchers, however, have concluded that the single biggest difference between the US and others is that prices charged in the US are substantially higher. How did all these problems develop? I believe that a major factor is that we have, with a few exceptions, consistently treated health care as a commodity to be bought and sold in the same manner as other consumer goods. The underlying belief has been that traditional market forces will insure efficiency, effectiveness and cost control. It has not worked. A clear example of this failure is right here in South Dakota. In eastern South Dakota we have intense competition between two major health systems. Given that, traditional market analysis would predict that our costs would be competitive. The reality is quite the opposite. In November 2022, Forbes magazine listed South Dakota as having the most expensive health care in the nation. Yes, there is intense competition but it is not focused on price. Competition is primarily on range of services, etc. In fact, some folks fear low cost care will be inferior even though lower cost can be a sign of just the opposite - prompt diagnosis, appropriate intervention and avoidance of complications. The US population - our families, friends and neighbors – deserve effective and efficient health care delivered at an affordable cost. We clearly are not there. We need careful analysis coupled with serious policy discussions free of the polemics which tend to dominate today’s discussions. We have a long way to go. But, it is important that we start. This article was previously published in SD Searchlight. Tom Dean, MD is a retired family physician who practiced for over 40 years in Wessington Springs, SD and a past member of the Medicare Payment Advisory Commission (MedPAC). Dr. Dean is a recent inductee into the SD Hall of Fame. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc®, a medical Q&A show providing health information based on science, built on trust, streaming live on Facebook and on SDPB most Thursdays at 7 p.m. central. Prairie Doc Perspective Week of August 13th, 2023
“Back to School, Back to School, Here We Go Back to School.” By Nikki Eining CSW-PIP, QMHP Here it is, August. Summer has flown by and already there is Halloween candy roaming the shelves of Walmart. For most of us, August also brings the normal adjustment of transitioning back to the school year. It is normal for this to look differently for everyone, especially depending upon the age of your child. You may find yourself stressing to find the school supplies list, supporting your youth through two a day practices for athletic season or looking forward to getting back to the routine of the school year. Adjustment is a term utilized often in the behavioral health world. Adjustment is “the process of adapting or becoming used to a new situation or stressor.” It is a change in our life. This possibly could be a change in the way we are doing something, our relationships, our employment, our family, our environment or possibly our routine. It is normal that with change comes stress. Stress can be positive stress, or it can be very uncomfortable. When adjustment, or change, is out of our control and creates this uncomfortable stress, it is important for us to explore and focus on “what is within my control.” This is where we can explore what is within our control as we adjust back to the school year. Here are some tips on things to think through that can be within your control:
With any adjustment in our lives, if stress symptoms continue after a month of change communicate with your primary care provider or local behavioral health care provider to explore how to support you or family members through this. Nikki Eining CSW-PIP, QMHP Outpatient Clinical Mental Health Therapist Avera Medical Group Behavioral Health Brookings Clinic in Brookings, SD. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc® a medical Q&A show based on science, built on trust for 21 seasons, streaming live on Facebook and SDPB most Thursdays at 7 p.m. central. Prairie Doc Perspective for the Week of August 6th, 2023
“Drug Prices” By Tom Dean, MD High costs and shortages of pharmaceuticals are serious, on-going issues. Drug prices in the US are among the highest in the world. A recent survey by the Rand Corporation looked at drug prices in 32 developed countries. US prices were the highest in the group and were more than twice the average of prices in other countries. What is especially troubling is that the products sold in many of these countries are the same drugs produced by the same manufacturers as those sold in the US at much higher prices. When it comes to drug prices, consumers – and even third-party payers – have little bargaining power. The reality is, drug companies are free to charge “what the market will bear”. Recently developed, brand name drugs are typically the most costly. New drugs are usually covered by patents which give the developers exclusive rights to market the product without competition. Patents are for 20 years and begin when a new drug application is filed. This usually occurs years before the product actually comes to market. Nonetheless, companies typically enjoy 10 or more years without any direct competition. When patents are nearing expiration companies have numerous ways to “game” the system. One of the most common is to make minor, often insignificant, changes in the product and apply for a new patent. Sometimes major producers actually buy up smaller potential generic competitors or pay such companies to delay the introduction of competitive products. Regulators have blocked some but not all such practices. The patent process is defended as a way to give firms some assurance that they can recoup the expenses they incur if they undertake the costly and highly unpredictable process of drug development. The public clearly has an interest in encouraging new drug development. Critics, however, have pointed out that often much of the early development is done in academic centers, usually at public expense. Even when patents expire the usual market forces do not always bring about effective cost control. The best example is insulin. There are three major producers of insulin who produce very similar products. Instead of competing on price all three companies progressively raised the retail prices of insulin. Insulin prices in the US climbed to as much as ten times those in Canada. Recent legislation has forced companies to limit out-of-pocket insulin costs for Medicare recipients to no more than $35 per month. Subsequently, public pressure led all three insulin producers to agree to a limit $35 per month for all users. In this situation competition produced real benefits. However, one wonders if the companies can afford to drop the price from over $100 to $35, what was their margin before the reduction? What about prices that are too low? Some older drugs are still vitally important. In several of these cases the prices – and the profitability – have dropped to the point where producers have left the market leaving us with seriously limited production capacity. Vincristine is a cancer drug, a key component in the treatment of childhood leukemia. Because of low profitability virtually all vincristine has come from a single manufacturer. When that producer ran into production problems no other source was available. Cancer physicians struggled for months with heart rending decisions of having to ration among seriously ill children the very limited amounts of vincristine they could get. There are other more recent examples. This past winter there were serious shortages of amoxicillin, a widely used antibiotic and, more recently, we are facing dangerous shortages of albuterol, a key treatment for asthma and COPD. In each of these situations the companies have made what they considered to be sound business decisions but decisions which were clearly not in the public interest. What to do? Open market principles have often served us well but we need to be smart enough - and tough enough - to recognize when we are benefitting and when we are not. We need regulatory limits that protect creativity and innovation yet prevent price gouging and insure availability of vital medicines. That is a high bar but one we as a society must keep working toward. Tom Dean, MD is a retired family physician who practiced for over 40 years in Wessington Springs, SD and a past member of the Medicare Payment Advisory Commission (MedPAC). Dr. Dean is a recent inductee into the SD Hall of Fame, these articles were previously published in SD Searchlight. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc®, a medical Q&A show providing health information based on science, built on trust, streaming live on Facebook most Thursdays at 7 p.m. central. Prairie Doc Perspective Week of July 30th, 2023
“Nasal Congestion” By Donald Bennett, MD One of the most common reasons a person comes to the Ear Nose and Throat clinic is a stuffy nose. The way the symptoms are described varies. The stuffiness or congestion can be present at all times, at certain times of year, worse on one side, alternate sides, and may or may not respond to medications. Getting this clear history and taking a close look helps me determine what are the causes and how best to help. The nasal passages are divided from left and right by the nasal septum, which is made of bone and cartilage. A deviation (or bend) of the septum is common, but can be more extreme in some cases and cause significant narrowing of the nasal passage on one or both sides. Some are born with this deviation, and it may worsen as the person grows. Sometimes a history of a nasal injury is present, which could have bent the septum or increased the chance it becomes more bent over time if the injury occurred in childhood. Within the nasal cavity are outpouchings called turbinates. A job of the nose is to prepare the air for the lungs, and it has structures that allow the air to be humidified, warmed and filtered. The turbinates are covered with a lining, called mucosa, which has numerous mucous glands and microscopic hairs. The turbinates are rich with blood vessels and periodically swell. This normal cycle of swelling can cause nasal congestion that alternates sides every few hours if the turbinates are excessively swollen. The turbinates can become excessively swollen for several reasons, including viral infections, irritation from dryness, or allergies to name a few. Turbinate swelling can respond to topical medications such as steroid and antihistamine spray. Medical management of allergies if present, including allergy shots, can improve and control symptoms over time. A less frequent cause of nasal congestion includes nasal polyps. These can be difficult to see from the front of the nose unless they are extremely enlarged. As an ENT, we often use a scope to see if these are present. A CT scan can also help. An even less frequent cause of congestion includes weakness of the cartilage of your nose. This can happen over time, or can be seen after an injury or prior surgery. A careful exam in the clinic can help determine if this problem is present. It is often managed with surgery. In most cases there is more than one cause of a person’s nasal congestion. If medicines do not improve symptoms, surgery can improve nasal breathing. A discussion with your surgeon on the risks and benefits to make an informed decision may be the next step. Dr. Bennett has been trained to provide comprehensive otolaryngology care. Dr. Bennett practices at Midwest ENT & Allergy in Sioux Falls, SD. His special interests include disorders of the ear/hearing, endoscopic sinus surgery, pediatric otolaryngology, head and neck surgery, thyroid and parathyroid disorders, voice and swallowing disorders. Follow The Prairie Doc® at www.prairiedoc.org and on Facebook featuring On Call with the Prairie Doc®, a medical Q&A show providing health information based on science, built on trust, streaming live on Facebook most Thursdays at 7 p.m. central. |
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