The Shifting Of The Crap

The real drug wars aren't cocaine and meth and marijuana. The ones you hear about on TV all the time. The real drug wars are fought on the battle fronts of the uninsured and underinsured. I remember starting my hospitalist position five years ago. The biggest battles were always, how the hell am I going to get granny to pay for the $300 inhaler that the pulmonologists started, or the $200 statin that the cardiologist started, or the $100 worth of antibiotics that I started. I used to to spend hours and hours of time trying to figure out how my Medicare patient was going to pay for their prescriptions. Less than five years ago, Medicare had no drug benefit. I couldn't send them home with lovenox shots for their DVT. They would spend 5-7 days in the hospital getting one shot a day because they couldn't afford the $1000 for the medication. Or they would come to the hospital twice a day to get their shots paid for under their Medicare Part B benefits. A perfect example of what I like to call The Shifting Of The Crap. Those things in health care that nobody wants to pay for, but somebody eventually will. The question is who.

Fast forward five years. Medicare Part D. It has revolutionized my ability not to have to deal with all that crap. It has revolutionized the social workers ability to not have to deal with all that crap. It has shifted the burden of crap onto formulary fights and insurance battles with pharmacists everywhere (sorry about that). Somebody is going to deal with the crap. The question is who. The Crap it is a shifting.

Then I think about generics. It's amazing what has gone generic in the last five years. Great medicines. Drugs that treat very common medical conditions from diabetes to hypertension to strokes to coronary artery disease. Some of the most common deadly and expensive diseases. Generics have lifted a huge burden in cost for patients everywhere. Again, more shifting of the crap. This time, patients win, drug companies lose. It's like a ping pong ball, bouncing from player to player each trying to avoid final responsibility at every step of the way. Where the crap ultimately lands, nobody knows. Everyone is trying to make money. And part of making money is dispensing of the crap. However you want to define it.

I compare it to the subprime mortgage market. Terrible loans repackaged into these really pretty collateralized debt obligations. And sold as AAA rated securities with promises of fairy princesses serving you lobster dinners. Marketed as a way to increase returns with little additional risk. Unfortunately, it didn't quite work out that way. Crap is crap no matter what kind of ribbon you put on it. Your no pay and low pay patients are your subprime mortgages (financially speaking). And everyone is in the game of trying to spread these obligations out, trying to minimize their financial crap exposure while ensuring maximum high profit returns. How you ask?

• Enter the specialty hospitals by invitation only
• Enter the urgent care centers
  
• Enter the call shortages in ER's everywhere.
  
• Enter Wally World clinics.
• Volume, Volume, Volume

You see the American health care system has perfected the intricate game of crap shifting. The main purpose of this game is to dump the cost of financial consumers on to the cost of financial producers. Maximizing the profit to risk ratio. Every player is doing it, from the insurance companies to device manufacturers to doctors to patients. Everyone, except the Medicare National Bank. They would rather pay $120 for a walker that costs $80 down the street. Perhaps our Congress should hook up with my friend.

Now, the rise in cheap generics has given everyone a fantastic opportunity to take control of their lives. To exit their status as the subprime patient. To treat their uncontrolled diabetes and hypertension and other assorted ailments. But you have to care about yourself first. A lot changes in 10 years. As a recent diabetic patient of mine found out. Diagnosed 10 years ago with diabetes, he was unable to afford his metformin, which at the time cost about $100 a month, he says.

So what does he do? He stops taking it. For 10 years my 45 year old has decided that since he can't afford it, he will ignore it. What happens when one ignores diabetes for 10 years? One comes to the hospital with a rip roaring skin infection requiring 3 visits to the emergency room and a $8,000-$10,000 hospital bill.

When I informed him that metformin went generic many years ago. That he can get it for $4 a month at Walmart. That he can get other diabetic meds for $4 at Walmart. His response?

"Sign Me Up"

For what ever reason, some people lack the intrinsic motivation to care about themselves. I can not force him to care. To take action. I can not force him to search out viable solutions to his problems. For whatever reason, there is a significant population that seeks mediocracy. That thrives in a nanny state. That feels perfectly compelled and satisfied with having others take care of their obligations. That feels no personal responsibility in living the life that they built. Maybe I should hook him up with my other buddy and the Medicare National Bank.

Perhaps they could all sit around and smile at each other.