A thought on reducing heath care costs

[Exterous]

During the much latter part of our two week trip to the UK I ended up with some notable chest congestion. I went to a local pharmacy and picked up some OTC chest congestion medicine at Bootes. The person running the register was the pharmacist and after a quick consultation I ended up with some much stronger behind the counter medicine. The consultation involved five sentences and maybe 30 seconds:
Are you taking anything else for this?
How long have you been coughing?
Do you have a fever, sore throat or heacache?
Here *hands me a box* this is much stronger.
Don't take anything else for this

On getting back to the US the medicine ran out so I went to get some more. Out of curiosity I took the box and looked for something with the same amount of active ingredients. Not surprisingly I didn't find any in the OTC section so I asked the pharmacist and was told that I would need a doctor's prescription for that combination/amount (Unfortunately my wife has since thrown the empty box out and I don't remember what they were). The OTC stuff I ended up with is noticeably less affective

As I sit here contemplating calling my doctor, having to take the time offered due to their busy scheduling, likely sitting in the waiting room for 20 minutes and paying $25 to see a doctor for 5 minutes before getting a prescription for something that took me 30 seconds and cost me $0 extra to get in Scotland it seems to me that offering pharmacists a slight latitude to hand out some slightly stronger medications might be something to investigate.

While I would imagine there are a lot of liability issues we would have to navigate it is my uneducated impression that this would reduce the number of required doctor's visits, lessening the burdens on families, employers and insurance companies for relatively straightforward diagnoses like 'he is coughing, lets give him something for a cough'

I do wonder if this would result in a noticeable negative impact on the general practitioner community though

 

[Hayabusa Rider]

Pharmacists associations have pushed for this and while in theory it sounds good I have considerable reservations. Imagine you are a pharmacist who has to wait on the drive through window, answer the phones, take prescription orders from the phone, the fax, electronically and fill them, spend an hour and a half or so out of each working day trying to deal with bureaucratic nonsense, run the register, take prescriptions at the drop off, give immunizations, and oh you don't have help, or you have so little that you have to do all these things anyway. You don't go to the bathroom when you need to. You might get a chance to eat but that's problematic. You answer ordinary customer questions about ibuprofen, etc.

Every second of your 12 hour day is managed, and Uncle Sam and private insurance want to cut the margins to negative so staffing is down or nonexistent. The pharmacist has the shortest life expectancy of health professionals due to working conditions. We've had two die last year at work.

Now we have MTM, which is a way of getting paid for professional interaction, which takes roughly 45 minutes per patient and the companies are hot to jump on this pile of cash. Well that's great. You do that while filling a prescription every 90 seconds and not being able to take a dump while working. More staff? Not a chance.

If you can fit your idea into the above without causing further damage I'd like to see it, but that won't happen. Mind you in theory I like it, but in practice it would be disastrous.

More patients, more tasks, less time and money. That's what all of health care is going to be faced with. We're just ahead of the curve. I've told my kids not to go into health care and they are listening. Other professionals are doing the same. The "solution" to health care problems is to give the taskmasters bigger whips. I don't think you can beat more work out of the slaves, and health care "professions" is becoming a joke.

Sorry, that was a vent, but it was also a very real account of what is happening and it's going to get worse.

 

[Juddog]

How about another idea - just make it a computer selection?

Patient gets prompted to answer the questions on a touch pad - gets medicine.

I know - too hard right? The computer can cross-reference every medication super fast and check it against the patient background (to see if any medicine they are currently taking would interfere or cause a negative reaction) and you take out the middle man.

The fact of the matter is that there is a great deal of healthcare that can be taken care of through computers, but it isn't, because there are too many hands in the cookie jar.

 

[Murloc]

I don't really think it would be a big improvement, maybe some bigger issue is behind the cough and the pharmacist can't just see that. Also what about liabilities?

Also I heard that in the UK you have to wait months to do medical stuff and exams because public healthcare gets overloaded, maybe they're cutting corners on this.

 

[Juddog]

I still think that currently about 90% of healthcare boils down to work that can be done by machines / robots / computers. The system is overloaded with garbage procedures and extra crap we don't need which is why the cost is overinflated beyond belief. Almost all pharmaceuticals can be boiled down to things which can be performed by machines / computers, most routine medical tasks can be as well.

I envision a future where the majority of reasons that people go to the doctor today will be safely done at the patients house instead. There is no reason to think that AI / robotics won't be able to be advanced enough in a few generations to perform simple procedures, such as stitching up a cut, measuring blood levels / performing blood tests, etc..

The healthcare system is incredibly bloated and inefficient beyond belief right now and needs some trimming of the fat.

 

[Hayabusa Rider]

I still think that currently about 90% of healthcare boils down to work that can be done by machines / robots / computers. The system is overloaded with garbage procedures and extra crap we don't need which is why the cost is overinflated beyond belief. Almost all pharmaceuticals can be boiled down to things which can be performed by machines / computers, most routine medical tasks can be as well.

I envision a future where the majority of reasons that people go to the doctor today will be safely done at the patients house instead. There is no reason to think that AI / robotics won't be able to be advanced enough in a few generations to perform simple procedures, such as stitching up a cut, measuring blood levels / performing blood tests, etc..

The healthcare system is incredibly bloated and inefficient beyond belief right now and needs some trimming of the fat.

You may envision such a thing, but you are wrong as to how it applies now. There is no system which substitutes for professional judgement at this time nor in the foreseeable future. We're "trimming the fat" by cutting staff to dangerous levels.

Unfortunately health care is very complex of necessity and therefore people who really don't know wish to change things despite that fact.

 

[Exterous]

Sorry, that was a vent, but it was also a very real account of what is happening and it's going to get worse.

No worries - I did notice that pharmacies were better staffed overthere and it would require some additional manpower to do this in the US. (I did not know that pharmacies were that bad though). I wonder if they could work out a billing rate for pharmacists consultation that was lower than a doctors for easier diagnosis like mine. Maybe I pay $10 for seeing the pharmacist instead of $25 for the doctor with the Health Insurance contribution likewise being less. Might allow for some extra staffing if done right (But the viability would depend on how much extra $ that generated for the pharmacy and I don't know how much that is used in the UK vs doctors)

I don't really think it would be a big improvement, maybe some bigger issue is behind the cough and the pharmacist can't just see that. Also what about liabilities?

I thought about that but at the time I was just getting some OTC cough medicine so a doctor wouldn't have noticed anything because I had no intention of going to see a doctor. If anything having the pharmacist there might help catch something sooner. "You've had the cough how long? You need to go see a doctor."

I do agree that liabilities would be an issue

 

[Hayabusa Rider]

No worries - I did notice that pharmacies were better staffed overthere and it would require some additional manpower to do this in the US. (I did not know that pharmacies were that bad though). I wonder if they could work out a billing rate for pharmacists consultation that was lower than a doctors for easier diagnosis like mine. Maybe I pay $10 for seeing the pharmacist instead of $25 for the doctor with the Health Insurance contribution likewise being less. Might allow for some extra staffing if done right (But the viability would depend on how much extra $ that generated for the pharmacy and I don't know how much that is used in the UK vs doctors)

That would be great, but both government and private insurance live to cut. If a funding mechanism comes in to boost resources they will cut elsewhere. Been that way for at least two decades. It's relentless, with money being the consideration, not quality of care, even at the cost of poorer outcomes and increased total costs.

This is a huge issue I have with Obamacare. It doesn't do anything that promotes quality of care worth mentioning. That would take knowledge and expertise, nothing in evidence.

 

[TraumaRN]

That would be great, but both government and private insurance live to cut. If a funding mechanism comes in to boost resources they will cut elsewhere. Been that way for at least two decades. It's relentless, with money being the consideration, not quality of care, even at the cost of poorer outcomes and increased total costs.

This is a huge issue I have with Obamacare. It doesn't do anything that promotes quality of care worth mentioning. That would take knowledge and expertise, nothing in evidence.

I have my reservations about ObamaCare but it does force some big quality changes on hospitals but it doesn't do two big things that are huge money wasters.

1.) It doesn't discourage the over testing/over proceduring of patients at all. I see this all the time. Thousands of dollars down the drain on tests that are of questionable utility based on patient's diagnosis and condition.
2.) It does NOTHING to stop the overuse and abuse of the emergency room. Again huge time and money waster. And since I work in the ER I should know.

 

[smackababy]

I think it is trying to address the ER abuse by forcing everyone to have health insurance. The idea was they couldn't afford a real appointment and since the ER doesn't turn away, opt for that instead and just not pay the bill. I mean, if you already have terrible credit, what is another collection added onto it?

I think the over testing might be from the fear of medical malpractice lawsuits. I know the insurance is outrageously expensive as it is. The fear of "oh you treated me for x, when I had y and it caused z; pay me $50 million" is probably not helping unneeded tests not be run.

As for the OP's idea, I think one of the major concerns is abuse. Cough medicine contains addictive and dangerous drugs and even over the counter medication is subject to massive abuse. European countries have always been more forward thinking than the US when it comes to actually doing something about drug abuse (educational leaflets concerning proper hydration and MDMA use and dirty needle exchanges are just a few examples). The US still thinks prohibition is a good idea rather than education and actual helping procedures.

 

[Hayabusa Rider]

I have my reservations about ObamaCare but it does force some big quality changes on hospitals but it doesn't do two big things that are huge money wasters.

1.) It doesn't discourage the over testing/over proceduring of patients at all. I see this all the time. Thousands of dollars down the drain on tests that are of questionable utility based on patient's diagnosis and condition.
2.) It does NOTHING to stop the overuse and abuse of the emergency room. Again huge time and money waster. And since I work in the ER I should know.

Remember when HIPAA kicked in? Sure it helped privacy but it was a nightmare. This? It's going to be a lot worse for you. Imagine you wanting to do tests but cant because of prior authorization. Do you need to spend another hour or two away from your patients to conform?

Instead we should be funding a secure database of patient history. It can be accessed biometrically and/or with NPI. Did a patient really get a treatment or have a test done? You'd know. Some will complain about how agencies would get health care information, but that's nonsense. They get it all now by looking at payments. Now that would be reform which would streamline a great deal, eliminate duplications of efforts, provide a sound medical history and on and on. If it cost billions it would be far far cheaper than what you and I know is done now and that doesn't count improved outcomes and a better quality of life.

Nope. Regulations.

 

[Juddog]

I think it is trying to address the ER abuse by forcing everyone to have health insurance. The idea was they couldn't afford a real appointment and since the ER doesn't turn away, opt for that instead and just not pay the bill. I mean, if you already have terrible credit, what is another collection added onto it?

I think the over testing might be from the fear of medical malpractice lawsuits. I know the insurance is outrageously expensive as it is. The fear of "oh you treated me for x, when I had y and it caused z; pay me $50 million" is probably not helping unneeded tests not be run.

As for the OP's idea, I think one of the major concerns is abuse. Cough medicine contains addictive and dangerous drugs and even over the counter medication is subject to massive abuse. European countries have always been more forward thinking than the US when it comes to actually doing something about drug abuse (educational leaflets concerning proper hydration and MDMA use and dirty needle exchanges are just a few examples). The US still thinks prohibition is a good idea rather than education and actual helping procedures.

I agree about the abuse thing - people will find ways to abuse just about anything. The answer lies not in limiting this and limiting that and slowly having everything limited, but rather to educate people on what they are doing to themselves (in terms of long term damage) by drinking an entire bottle of cough medicine to trip out, etc..

I'm still pissed about pseudoephedrine turning into some kind of restricted substance; I'd use it once in a blue moon when my allergies were going bonkers because it didn't make me feel drowsy like most of the OTC medications nowadays do. The non-drowsy medicine seems to be either not effective or has some other weird side effect - pseudoephedrine was just about perfect. So some crackhead / meth head wants to use it to make speed - who cares?

If we didn't have a prohibition approach in the first place and spent the money on education for what they are doing that's hurting themselves, it wouldn't be such an issue in the first place. If someone wants to buy some crap and overdose on it, then let 'em - let the patients have all the info, electronically in their hands, to decide whether they want a drug or not. There is a mountain of research data available; we need to scale back the amount people can sue for and in turn allow more medicine to be OTC, as long as the patient steps through an electronic form which compares all the medications they're taking, gives them a big explanation of the side effects, and then agrees to the terms and conditions.

The ER visit thing is messed up as well; people have no healthcare so they wait until something is critically wrong and go straight to the emergency room, or alternately go there for something that doesn't need it. Universal healthcare (e.g. Canada's system), combined with data analytics and computerized forms, would allow the cost of healthcare to be trimmed way down, would reduce the "middle man" effect from health insurance, and increase the quality of care all at the same time by educating patients with what they're taking / doing.

The entire system needs an overhaul in a major way.

 

[smackababy]

Remember when HIPAA kicked in? Sure it helped privacy but it was a nightmare. This? It's going to be a lot worse for you. Imagine you wanting to do tests but cant because of prior authorization. Do you need to spend another hour or two away from your patients to conform?

Instead we should be funding a secure database of patient history. It can be accessed biometrically and/or with NPI. Did a patient really get a treatment or have a test done? You'd know. Some will complain about how agencies would get health care information, but that's nonsense. They get it all now by looking at payments. Now that would be reform which would streamline a great deal, eliminate duplications of efforts, provide a sound medical history and on and on. If it cost billions it would be far far cheaper than what you and I know is done now and that doesn't count improved outcomes and a better quality of life.

Nope. Regulations.

But... but... what if the NSA looks at the data? They will know my entire medical history! My privacy will be completely gone, regardless of the fact I checked myself in at the doctor's office on Facebook and posted #herpes? #hopenot with it.

 

[piasabird]

American health care is all about controlling people and changing them for medicine that is weak and will not work. Then when you do go to the doctory with congestion the doctor says if it gets worse come back and I will prescribe an antibiotic. Why do you have to wait till you are 5 times worse before they give you an antibiotic when they could have given you that 3 days ago and now you feel like your head will explode? Doctors love to make people suffer.

 

[TraumaRN]

I think it is trying to address the ER abuse by forcing everyone to have health insurance. The idea was they couldn't afford a real appointment and since the ER doesn't turn away, opt for that instead and just not pay the bill. I mean, if you already have terrible credit, what is another collection added onto it?

I think the over testing might be from the fear of medical malpractice lawsuits. I know the insurance is outrageously expensive as it is. The fear of "oh you treated me for x, when I had y and it caused z; pay me $50 million" is probably not helping unneeded tests not be run.

As for the OP's idea, I think one of the major concerns is abuse. Cough medicine contains addictive and dangerous drugs and even over the counter medication is subject to massive abuse. European countries have always been more forward thinking than the US when it comes to actually doing something about drug abuse (educational leaflets concerning proper hydration and MDMA use and dirty needle exchanges are just a few examples). The US still thinks prohibition is a good idea rather than education and actual helping procedures.

First off as much as I'd like to share your optimism about more people having insurance means less ER visits, I just can't see it. Most of those that are uninsured now will be put on Medicaid, which has ZERO co-pay for ER visits. And honestly the worst abusers of the ER in all 3 hospitals I've worked at were Medicaid patients. They knew they would wait less in an ER, could come at any time of day or night, we are open 24/7/365, AND they didn't have to pay anything.

The particular ER I work in now has become so efficient on it's own that we are partially feeding this problem but it is a problem nonetheless because these people don't NEED to be in the ER in the first place. I know the UK has a public ad campaign about using the ER ONLY when it is necessary, however given how EMTALA(basically EMTALA=we have to treat you no matter what) has almost all ER's by the short hairs I highly doubt we will ever see something like that here.

Your 2nd point about malpractice insurance and lawsuits is SPOT ON. We do so much in the ER because frankly we don't want to get sued. It's why we do cardiac/heart attack rule outs on 27 year old patients because you get that one 27 year old ONE time that has a heart attack and you miss it...it turns into a kind of mentality, OVERDO EVERYTHING!. The hospital and to a larger extent the government and insurance companies almost have an expectation that we be robots that miss nothing and catch every rare disease/disorder. Frankly, it is ridiculous.

As far as your last point, I agree about potential for abuse but given the fact that the US is far and away the leading abuser of prescription opiates...it rings a bit hollow. You are correct in that we approach it the wrong way, preferring to just throw people in jail rather than to educate them about the dangers of those medications. Moreover I hold the FDA personally responsible for many of the issues we have regarding opiate abuse in this country. I'd love to see some serious restrictions on prescribing percocet/vicodin/etc but that just won't happen. Instead I just get to continue shaking my head at getting patients into the ER that get prescribed Percocet by an ortho doctor for a sprained ankle and suddenly this opiate naive person isn't acting right and the family freaks out and into the ER they come. Insanity. There are so many opiates out there for use in humans, many with LESS abuse potential(and less cardiovascular/respiratory/neuro depression) than percocet, vicodin et al, yet they are not approved for use here in the states.

 

[DaveSimmons]

This is another reason why I support legalizing at least marijuana as a start.

If people can get reasonably cheap, high-quality and safe marijuana the same places they get their booze and cigarettes then there will be less demand for abusing cough syrup. Possibly those with addictive personalities would also choose it over more destructive street drugs like meth.

Take away some of that abuse, and the restrictions on decongestants and cough syrups might be relaxed.

You are correct in that we approach it the wrong way, preferring to just throw people in jail rather than to educate them about the dangers of those medications.

Edit: or to take what TraumaRN said to its conclusion, legalize everything and focus on education, treatment and rehab instead of jailing addicts and providing billions in funding to criminals by giving them a monopoly on street drug sales. When you can buy meth at Wal-mart, the dealers, crack houses and exploding meth labs may disappear.

 

[Hayabusa Rider]

But... but... what if the NSA looks at the data? They will know my entire medical history! My privacy will be completely gone, regardless of the fact I checked myself in at the doctor's office on Facebook and posted #herpes? #hopenot with it.

As I said the information already exists. It's not secret, it's not hidden, it's not new. It's a matter of coordination and access of resources of data already known, but not organized to be beneficial.

 

[Whiskey16]

You may envision such a thing, but you are wrong as to how it applies now. There is no system which substitutes for professional judgement at this time nor in the foreseeable future. We're "trimming the fat" by cutting staff to dangerous levels.

Unfortunately health care is very complex of necessity and therefore people who really don't know wish to change things despite that fact.

Exactly.

The problem of relative cost in the USA is hardly that of the OPs argument against prescriptions needing authorisation by validated health care professionals who are responsible and directly aware of the care for their patients. The major relative pitfalls of the US health system is redundancy and for-profit margin hording by insurance and medical bureaucratic entities. Then one can add the ills of the general lack of regular general preventative care and early screening for those in the US lacking a GP or non-payment access to a walk-in clinic, through to excessive profiteering for pharmaceuticals, etc..

For the OP, a pharmacist is not trained for diagnosis and care. Their training enables a responsible duty to safely distribute and advise upon pharmaceuticals and be aware and counsel a patient upon the proper use of diagnostic equipment. If you have a concern towards a GP or other medical doctor being required to assess for and write a simple prescription, then less expensive solutions are already being implemented and extended. Such are with Licensed practical nurse (LPN) and through to midwives.

 

[Exterous]

As for the OP's idea, I think one of the major concerns is abuse. Cough medicine contains addictive and dangerous drugs and even over the counter medication is subject to massive abuse. European countries have always been more forward thinking than the US when it comes to actually doing something about drug abuse (educational leaflets concerning proper hydration and MDMA use and dirty needle exchanges are just a few examples). The US still thinks prohibition is a good idea rather than education and actual helping procedures.

If cough medicine can already be abused through OTC means then I am not sure what how much extra abuse is going to be seen by allowing a pharmacist to occasionally dispense stronger amounts. Its not like requiring a prescription has affectivley combated pain killer abuse.

I do agree with you that we are trying to combat the problem the wrong way

The problem of relative cost in the USA is hardly that of the OPs argument against prescriptions needing authorisation by validated health care professionals who are responsible and directly aware of the care for their patients.

I did not state or imply that the relative cost of health care is mostly affected by situations like I outlined above. That does not mean that it could not serve as a cost reduction mechanism. (It also doesn't mean that it could)

For the OP, a pharmacist is not trained for diagnosis and care.

I am not sure the point of this statement. Clearly pharmacists are diagnosing people and dispensing medication. They may not do that in the US but the UK empowers them with rudimentary diagnosis leeway and, I would assume, provided training to do so. You could argue that the training would be expensive and unwieldy but merely pointing out that the training does not currently exist is not a strong argument, not to mention a false blanket statement

If you have a concern towards a GP or other medical doctor being required to assess for and write a simple prescription, then less expensive solutions are already being implemented and extended. Such are with Licensed practical nurse (LPN) and through to midwives.

The concern was not just prescribing simple prescriptions but the process of obtaining one as well. Until a LPN or midwife is at a local store requiring no appointment or noticeable wait time a large crux of my complaint/suggestion remains. I am not saying that my complaint or suggestion is valid/will work/could actually be implemented by the US but this point really doesn't address a large part of it.

 

[randomrogue]

You can't lower healthcare costs without tort reform. The reason healthcare is a mess is because doctors machine gun you with all these different tests so they can't get sued for missing something.

Pharmacists are highly trained but at what point do you want to limit their powers? Pain medication? Until every state has a better centralized system in place to stop pain medication abuse this won't work. Just look at Florida.

 

[poofyhairguy]

You also can't lower healthcare costs without shifting patient expectation and rationing.

As it is because healthcare is a product in America, people want to bring the "customer is always right" attitude even if its actually someone else paying. "I DEMAND this hospital does every possible expensive procedure so grandma can live another day!" Death panels were a political talking point, but really we waste so much care with hypochondria and self-importance that without rationing costs will never be controlled.

And to get there I unfortunately think you have to bottom out the quality of care in the current system. Make it so that its SOO painful on both sides (doctors and patients) to deal with insurances/Medicare/Medicaid/exchanges/etc. that eventually doctors say "we will take the lower salary check from the government" and patients say "we will accept rationing" in both cases "to just get rid of the headaches" of the current system.

At the point where doctors are government employees that fixes tort reform too. When its the government paying the medical malpractice lottery is over.

 

[brianmanahan]

things don't seem to have gotten any better since 2013

though at least it's still possible to buy health insurance that covers preexisting conditions

i don't expect that to last though

 

[IronWing]

Doctors aren't going to give up their monopoly on prescription writing. It is the primary source of their wealth.