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The Leviathan Swims In The Swill: Too Much Money To Ever Fix The System

I’m not quite sure where to go with this. Each week I flip through dozens of medical articles in an attempt to find one or two interesting health care developments you may not have read about. This week, I found myself tossing one article after another into a stack I mentally labeled “greed and its consequences.”

Now no one, whether person or corporation (rendered equivalent by the Supreme Court), wants to be labeled greedy. Neither is simple greed a criminal offense. In fact, greedy people and corporations are generally adept at morally (or, in the case of health care, scientifically) justifying their actions. A surgeon caught doing unnecessary procedures and a hospital CEO awash in fraudulent billing charges would be shocked and offended if someone accused them of anything as base as greed.

And yet my Greed Pile continues to grow.

Hospice Inc
I was most surprised to learn about the widespread abuses throughout the hospice industry. About 25 years ago when I was doing a lot of geriatric medicine, hospices for patients with terminal illnesses began to open, usually in a converted floor or wing of a not-for-profit hospital owned by a Catholic order of nuns. The family doctor would visit, the patient kept comfortable, sipping soup proffered by an elderly nun, until the end quietly came. No heroics, no last minute saves, just death.

It may interest you to know that currently half of Medicare patients will die in hospice, and since Medicare picks up most of the hospice bill we’re now talking serious money. Hundreds of hospices are scattered across the US, most operated by large corporations collecting more than $15 billion a year, all in your tax dollars. So what’s the problem? Medicare fraud and abuse. Investigators found that hospices were billing for charges as if they were hospitals, but without supplying hospital services. In fact, much of the care appears to be mediocre. In addition, unlike nursing homes, which are inspected every 15 months or more frequently, hospices can go years without anybody taking a peek.

Currently all the major hospice chains are undergoing fraud and abuse investigations and the picture being painted is not pretty. In the interim, these same chains have sent their sales force out in droves, trying to get hospitals, physicians, and families to consider hospice for their loved ones. One of the biggest complaints is inappropriate admissions, meaning expensive “terminal care” for the not-particularly-terminal. You can read more about all this here.

Big Pharma and health insurers
Everyone’s favorite greedy pair, the pharmaceutical and health insurance industries, are engaged in a major battle these days and unfortunately you, the patient, are the battlefield. Drug prices have become obscenely high. I recently overheard a pharmacist tell a customer that the small tube of ointment she needed was not covered by her plan and would cost $750. Thinking she’d misheard, she kept asking him to repeat it. He was extremely patient, but finally said, “Yes, it’s insane. Completely insane.”

How this tube of ointment, a drug that’s been around for almost 30 years, got priced in the stratosphere is an interesting study in simple greed and you can expect more like it.

Here’s how it goes: A group of big-money investors with absolutely no pharmaceutical expertise learns that an older generic drug has gone off the market, either due to lack of sales or because it’s been replaced by better drugs. Now it’s called an “orphan drug.” They buy the rights to this drug, and if anyone else is manufacturing it they’ll buy those rights too. Now the orphan is theirs, not unlike orphan girls in Victorian times who were promptly sold into prostitution. The drug is renamed and manufactured/packaged either here in the US or somewhere overseas. The orphan gets new clothes and a new identity. Its owners hire a sales force and spend a fortune pimping her out. Clearly the biggest savings for investors is that the drug has already been FDA approved. No testing, no expensive clinical trials.

A quick example of this is the migraine drug Midrin, discontinued in 2009 when the FDA classified it as “possibly effective” and in any case being left in the dust by the triptans (Imitrex, et al.). Midrin went generic and, because it didn’t work particularly well, was very inexpensive. Enter the Big Money Boys. Midrin received a new name, Nodular, marketed as “another migraine choice.” It is quite expensive. When I commented to the drug rep that the FDA says it’s not a very good drug, she answered, “Well, some people like it.”

The health insurance companies are pushing back on this greed and denying coverage for expensive drugs like these. But in the process they’ve learned there’s big money to be made by denying prescription drugs. If you’re a regular user of prescription drugs, you’ve likely seen a medication you’ve long taken suddenly being denied, or you’ve been told you must switch to a generic–and not just any generic, but the one that’s listed in your insurance company’s formulary. You might even be forced to use a drug you’ve tried in the past and know doesn’t work. Too bad for you.

Some of these denials are the result of sweetheart deals between drug company and insurance company. The asthma inhaler ADVAIR saw its market share plummet when it couldn’t match the price of its competitor, Symbicort. Most denials involve new drugs. Your insurance company insists your doctor must prescribe two or more drugs of the same class even if your doc knows the drugs won’t work for you…or aren’t even FDA approved for your condition. This is called “first fail” and compels patients to take ineffective drugs (and endure side effects) for the sole purpose of enhancing corporate profits.

Hospitals and doctors too
Hospitals and physicians are right there with the rest when it comes to self-justifying greedy behavior. I’ve already written about the egregious billing techniques of hospitals to cover the multi-million dollar salaries of healthcare “executives.”

An all too frequent topic in hospital board rooms is not “How can we do better?” but rather “How can we do more…” (cardiac catheterizations, colonoscopies, cataract extractions). “We need more referrals to cover that new…” (gamma knife, PET scan). “More patients to fill our new”….wing, nursing home, and yes, hospice.

As a primary care provider, I’m seeing more and more unnecessary diagnostic and surgical procedures being performed on patients. This has been confirmed by data collection and record review. This article shows that 30% of total knee replacements were probably unnecessary. This one discusses the booming sleep apnea business. The diagnosis of obstructive sleep apnea can be iffy, and recommendations for a CPAP machine or corrective surgery come long before any advice on lifestyle changes (like weight loss or sleeping on your side).

How long before you find yourself wheeled into an operating room if your nasal septum is a bit crooked, you complain of back pain, or you’re constipated?

If you mention a specific symptom to your doctor, you must learn to expect a prescription before hearing about lifestyle changes. Your doctor makes more money by moving fast. Writing the prescription ends your visit. She can now move on to her next patient. Oh, and let me add here that each year 3.5 million doctor visits are triggered by side effects. Women report nausea as the #1 side effect. The top drug side effect among men (obviously reported by the doctor or family) is death.

What does all this mean? Very simply, you must make every effort to avoid a potentially fatal encounter with the Leviathan of greed known as the US Health Care System. One study after another has proven beyond a doubt that if you take care of yourself, eat a healthful diet, exercise regularly (all year round), and consciously reduce stress, you can avoid the swill of chronic illnesses in which the Leviathan is swimming, waiting…for you.

Be well,
David Edelberg, MD


Leave a Comment

  1. Dr. David W Bailey, DC says:

    Indeed, Dr. Edelberg, indeed.

  2. arletta williams,...great to be informed!!!! says:

    Thanks,for your time & the needed info ,I,ll be on top of it now..

  3. Susan Barney says:

    Word. Thanks Dr E

  4. Dear Dr. Edelberg,

    What do you know about Product B – a blend of many “natural substances” that is supposed to heal your telomeres? My daughter (in Ft. Collins) knows someone who is selling the product and she would like to try it if it is thought to be helpful for increasing energy. She is going through a rough change-of-life period. I told her I would ask Dr. Edelberg’s opinion. Thank you
    Bev B

  5. Dr E says:

    Hi Beverly
    Product B contains a little of just about every herb and supplement associated with “anti-aging.” Whether or not these mini-doses when combined together actually do anything beneficial is another issue altogether. They’re all pretty harmless. If you live a long time, you can always attribute your longevity to Product B. If you develop some serious illness and die younger than you think you deserved, especially after using Product B, you can (from the other side) demand a refund.

  6. Any thoughts on how we as individuals , collectively, can “stem the tide?”

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