Lack of access to medical care gets all the attention. But the epidemic that slaps me in the face each day is excessive medical care. The medical scene is rampant with too many diagnoses, medications and procedures that add little to health care value except excess cost.
The main drivers of costly and unnecessary health care costs are over-expectant patients who believe a swallowed pill can correct anything; pharmaceutical companies whose advertising dollars can create diseases to fit any newly patented drug; and medical schools run on multiple-choice testing that deemphasizes independent thinking by budding physicians.
Comparison of state-by-state health statistics shows the not-unexpected dismal “state of health” status in Louisiana compared to national averages.
Our Louisiana infant mortality, teen death, AIDS diagnosis and childhood obesity rates are all well above national averages. Our adult population is more overweight and less likely to visit the dentist. We are more likely to end up in nursing homes, and we die younger. Our poor health statistics cannot be explained by unhealthy habits and high poverty rates alone. Our mindsets across all economic levels need a major alignment.
“I’m tired all the time. I need you to make me appointments for a cardiologist, a urologist, a neurologist and a foot doctor. And I need you to write me prescriptions for all these,” said a newly minted Medicare patient from Metairie on his first appointment with a new primary care physician. He emptied a Rouses bag of prescription medications, some dating back years, on the consultation table.
He didn’t have any cardiac symptoms or history, he just wanted to get his heart checked. He wanted to see a urologist because he woke up a couple of times at night to urinate and also wanted “to try Viagra.” His memory was “slipping” so he wanted a neurologist to check him out for Alzheimer’s and his wife said he needed an MRI. And he wanted his toenails cut for free because the nail salon his wife carted him to had gone up to $20. A friend told him Medicare would pay a podiatrist to clip his toenails if referred by his primary care physician.
His prior physician, a “high writer” in drug salesman lingo, issued prescriptions like a Metairie household hands out candy on Halloween. But in this case, the candy was causing some of his problems. Anyone who has taken Ambien every night for five years is going to be tired. His blood pressure medications were illogical combinations of the newest and most expensive Big Pharmaceuticals has to offer. In addition, he was overweight and smoked.
What is the difference between the man from Metairie and a Paw-Paw in Iowa? Louisiana residents cost Medicare $3,239 a year more than their peers in the Hawkeye State, according to StateHealthFacts.org. These costs reflect increased hospitalizations, procedures and more expensive treatments. Prescribed drugs are another area where our senior citizens far outspend the national average. Sit back and let me vent on just three groups of drugs that I believe are often over utilized in our area.
Arthritis drugs. Osteoarthritis is a good example of an overly treated medical condition and a prime example of less being safer. Over time normal aging and “wear and tear” on joints are pathways to this kind of degenerative arthritis, a condition almost everyone has to some degree by age 70.
Pain and anti-inflammatory medications are first-line treatment options for osteoarthritis. All many folks need are properly dosed aspirin or Tylenol for a few days. The generic counterparts of Motrin, Naprosyn and Mobic work better for others. The occasional flare of joint pains and stiffness responds well to what physicians call “PRN” or “take-as-needed” medications. One way to take these medications is to start at the first sign of a flare, continue for a week or so and then taper off the medication over another week. It will be months before many folks get another flare of joint discomfort and stiffness.
Ask your physician about taking lower doses less frequently. All some folks need is a small nighttime dose to erase early morning joint stiffness or maybe extra medication before certain activities. Anything to reduce the intake of anti-inflammatory medications lessens the likelihood of many adverse effects including gastrointestinal bleeding and kidney damage.
Celebrex is a prime example of the trail of deception that crops up with the regularity of the changes of the seasons in New England. Early studies showed Celebrex was no more effective than ibuprofen, but the company made hay on a claim that it was easier on the tummy. The drug company funded studies that compared drugs in illogical dosages, massaged the data to make Celebrex look safer and paid local physicians across the United States to be their disciples under the guise of in-service education delivered in the private dining rooms of expensive restaurants. In just-released court documents, drug company executives e-mailed each other about cherry picking data and how physicians at a medical conference “swallowed our story, hook, line and sinker.”
Persons who do need long-term regular anti-inflammatory medications are usually best treated by generic versions. I see patients weekly who swear Celebrex is the only arthritis medication that works for them. In some cases they may indeed be unique responders, but testimonials aren’t data. How a physician presents a specific medication goes a long way in how it works. Consumer advertising for newer and expensive drugs lulls both patients and physicians to trade-name drugs that really offer less with more adverse effects in the long run. And the drug company marketing and advertising works. According to press reports, Celebrex brought in $2.5 billion for Pfizer, including prescriptions for 2.4 million folks in the United States in 2011 alone.
Nexium and its cousins. Everyone has seen ads for “the purple pill.” Again, advertising works. Physicians in the United States write over 100 million prescriptions annually for Nexium, Prevacid and similar drugs called proton pump inhibitors or PPIs.
The FDA-approved package inserts for Nexium and the other PPIs are clear. In most cases they should be prescribed for only one to two months to treat heartburn symptoms from reflux of stomach contents into the esophagus. In certain situations therapy can continue for six months. Even though there are no controlled trials addressing long-term safety, most persons who begin these drugs stay on them for years. I know. I write prescriptions for these drugs almost every working day. Why? Patients get addicted. Stopping Nexium or another PPI after several months causes a sudden intense rebound of the original symptoms. It doesn’t hurt that insurance companies and Medicare pay most of the $100 billion a year spent on these drugs.
“Well, they aren’t hurting me, so I just as soon keep taking them. Besides, my insurance pays for them. I have to pay for Tums myself,” said Mrs. Y last month. It is a response I hear frequently when I try to wean a patient away from them. I explain how acid is in the stomach for good reasons. An acid bath kills most ingested bacteria. Mixing food with acid in the stomach also releases important nutrients for absorption including calcium, magnesium and essential vitamins.
These biochemical changes aren’t just test tube phenomena. After three months of a daily PPI, blood levels of magnesium fall, which can set off cardiac irregularities. Persons on long-term PPIs are more prone to certain gastrointestinal bacterial infections. Decreased calcium absorption translates into weaker bones. Wrist, hip and vertebral fractures increase when folks take way overprescribed drugs for more than a year.
So what’s a person with heartburn to do? First of all, persons prescribed Nexium or other tradename PPIs costing up to $8 a day, should ask their physician for a generic PPI or switch to an over-the-counter version or Prevacid and Prilosec. All these drugs are essentially equally effective and even sticking your insurance company with the cost for Nexium is akin to throwing your mother’s Mignon Faget jewelry into the Mississippi River.
Most persons on long-term PPIs would be best served by seeking out a physician who will reassess their need for this therapy. Gradual withdrawal with dosage tapering can take a couple of months. Effective step-down drugs, including antacids, are the preferred preventives and treatment modalities for most heartburn sufferers.
Long acting antihistamines. New Orleans, what with our humidity, heat and biomass of plant growth, is Ground Zero for respiratory allergies. The histamine release caused by breathing in our spore-laden air affects most of us. Antihistamines can block the respiratory tree receptors that cause mucus membrane irritations, itchy eyes, tickling coughs and runny noses. A short-term seasonal use of these drugs can really be beneficial for many folks.
After drug companies first released the less-sedating antihistamines, an uptick in their long-term daily administration ensured. Zyrtec and Clarinex combinations were initially by prescription only and covered by most insurance companies. People began taking these drugs all year long. Once the patent for Clarinex expired in about 2002, the company began selling it over-the-counter. Since there was now a less-sedating antihistamine available without a prescription, insurance companies covered fewer and fewer costs for all drugs in this class, and the explosion of daily dosing all year long mostly dissipated as quickly as it had initially soared.
Any antihistamine with a “D” at the end of its name is usually a combination drug also containing a decongestant. Long-term use of these combinations is rarely, if ever, needed. Dr. Michael Ellis, the local guru on responsive prescribing for nasal allergies, shared his thoughts on this matter with New Orleans Magazine readers in May 2005 (MyNewOrleans.com/New-Orleans-Magazine/May-2005/News-for-Noses). If you have rhinitis problems, a reread of his advice is in order.
The bottom line: Too much medical care may be even more dangerous than not enough. In Louisiana we pay more and our outcomes are substandard. We have ourselves to blame.