Adjunctive Therapy

In addition to the exorbitant costs that HMOs have engendered in the delivery of health care, two other factors, ones that may be more difficult, but not impossible, to solve, include the high cost of prescription drugs and excessive malpractice premiums.

In the July 5, 2008 edition of the Youngstown Vindicator Mr. Ernie Brown wrote, “The next president of our country will again have to deal with the seemingly impossible problem to solve — providing low-cost, quality health care to millions of Americans who are without that coverage.” As I have shown over that past several weeks, the “seemingly impossible” ailments currently suffered by our health care systems are not “impossible…to solve” but are definitely curable by means of a surgical excision of the primary problematic system (that means we cut out the middle, bureaucratic HMO layer that costs so much) and through the reinstitution of that delivery system which worked so well prior to the federal government’s 1965 introduction of Medicare and the insurance industry’s patently obvious mismanagement of healthcare; that reinstituted delivery system is what is generally known as that good old fashioned, American style of business called free enterprise. Doing that will drive down the cost of care and make even the uninsured better able to cope. Today we will discuss two other, post-operative, adjunctive therapies for treating our ailing system of health care.

In Mr. Brown’s article he alluded to “A 2005 story from The New York Times (that) says 10 major pharmaceutical companies joined in (what they termed) Together Rx Access to cut 25 to 40 percent from the retail prices of prescription drugs sold to uninsured people of modest means younger than 65.” Parenthetical remarks were mine. He went on to say that “ Roba Whiteley, executive director of Together Rx, said, ‘We are in a difficult moment right now in our economy, and if people can know about saving money on their prescription medicine, that will be a big help.”’ Mr. Brown also pointed out the fact that “one in five black adults is uninsured, which accounts for 6 million people in the U.S. More than one in three Hispanics does not have health or prescription insurance. Although the majority of Hispanics work, they are less likely to have health coverage as they may be recent immigrants or employed in low-wage jobs with no benefits.” Also according to Mr. Brown, “the companies participating in Together Rx Access are Bristol-Myers Squibb Co., Glaxo-Smith-Kline, and Pfizer.”

If the pharmaceutical companies can afford to supply lower cost drugs to minorities, why not also provide medications to those other people in the US who also work but whose middle class incomes do not afford them the luxury of having a reduction in their drug bill? There are ways that the pharmaceutical industry can cut the fat out of their business practices and pass those savings on to the customers. Of first importance is advertising. That used to come strictly by way of pharmaceutical representatives (I.e. salespersons) who called on doctors during office hours and informed them of the latest advancements in their product line. While that method is still in practice, an extremely irritating, offensive and quite expensive form of advertising is also being used; namely through the television and radio media. Drug companies also flood medical journals with page after page of advertisements. There is nothing that frustrates a physician more than having a patient come in to the office having made his or her own diagnosis and demanding a prescription for that alleged condition. The commercials promoting drugs to treat erectile dysfunction are not only unnecessary (since anyone with that condition will seek the counsel of his physician), they are also in extremely bad taste, given the fact that they appear on the screen during prime time, suggesting a private love making episode when young folks are sitting with their parents or grandparents watching a sporting event (and not the one being suggested by the ED commercials). While watching the Golf Channel last Sunday afternoon I saw three separate ED drugs (Cialis, Viagra and Levitra) being advertised in a span of 60 minutes. Another, equally offensive product promotion concerns the drugs that are used to treat the sexually transmitted disease known as herpes simplex. Drug companies likewise advertise specific cholesterol lowering agents, treatments for athletes foot and drugs to shrink the prostate; just to name a few. During 2004, the U.S. pharmaceutical industry spent 24.4% of its 235.4 billion sales dollars on advertising, versus 13.4% for research and development, as a percentage of US domestic sales of US. Thus 57.4 billion dollars were utilized on ads. Consider how much they could have reduced the cost of drugs if they had expended only half that much.


The pharmaceutical companies used to offer certain perks to doctors, such as a free dinner out with one’s spouse while being lobbied after dinner by the pharmaceutical representative as he or she promoted a new miracle drug soon to be released. Weekends in a luxurious hotel, all expenses paid, were formerly offered as were various items to be used in practice from pen and pencil sets to blood pressure cuffs to stethoscopes. Thankfully, very little of that goes on any more but there are still some unnecessary perks that could be eliminated in order to reduce of cost drugs to the consumer. According to an article appearing in the 8-13-08 issue of JAMA, the pharmaceutical industry spent $168 million on lobbying members of Congress in 2007 and $20 million on campaign contributions, a sum exceeding that of any other industry. The number of employed pharmaceutical lobbyists in 2000 was 625, more than one for each member of Congress. An analysis of official lobbying disclosure records by other agencies, found that the industry recruited high-priced talent, paying individual lobbyists on average more than $12,000 a month. The issues of concern to the drug industry involved, patent protection, blocking the importation of less expensive drugs and ensuring greater market access in international trade agreements. In regard to patent protection, once the particular company has recouped its costs for research and development of a particular pharmaceutical agent, only the cost of producing it plus a reasonable profit margin should be passed on to the consumer; by reducing the cost to that which is competitive with generics, patent protection will become a moot point. By limiting the amount they spend on lobbyists and advertising, patients would benefit greatly. There ought to be a cap placed on those spending issues.


A second method for reducing the cost of healthcare would be to institute tort reform. Tort reform refers to the idea of changing the rules applicable to the laws of tort. Tort deals with compensation for wrongs and harm done by one party to another's person, property or other protected interests (e.g. reputation, under libel and slander laws). The most contentious area in question has to do with tort reform which advocates its focus in personal injury and that specifically involves malpractice insurance. There needs to be a cap placed on allowed damages and those attorneys and their clients who file frivolous suits, that either never make it to court or are lost in a trial, need to be held accountable for capricious acts and thus required to pay reciprocal damages to the physician to cover his/her legal expense, time lost from practice and reputation damaged. If that is the case they will think twice before taking a physician to court. As tort law stands now, the suing patients and the lawyer representing them are in a no risk situation; they have nothing to lose in filing a suit.


A 2005 study by Dartmouth College researchers suggests that huge jury awards and financial settlements for injured patients have not caused the explosive increase in doctors' insurance premiums. The researchers said a more likely explanation for the escalation is that malpractice insurance companies have raised doctors' premiums to compensate for falling investment returns in other market areas. If that is so, the practice is what one calls highway robbery. When I started my practice in 1967, malpractice suits were rare occurrences and I paid a mere $300 per year for $100,000 (single event) and $300,000 aggregate coverage. When I retired in 1998, having never been sued, my malpractice insurance premium had risen to $7,000 per annum for one million (single event) and two million (aggregate) coverage. Now an internist, the lowest physician on the scale of risk, pays as much as $25,000 annually for the same coverage and OB/GYN physicians in Dade County Florida pay $250,000 per year. That is because the current law states that an obstetrician can be sued until a person reaches the age of 21 if any ailment up to that point can be shown to have been caused by the pre-natal care and/or delivery. Not only does part of the cost of that high premium get passed on to the patient, but the doctor is forced to practice defensive medicine and order a lot more tests to cover his or her potential liability than would otherwise be needed. A urologist friend of mine was once sued by an insurance salesman who had been kept waiting in the physician’s office because of an unforeseeable, surgical emergency. He sued for the loss of an insurance policy sale because he had missed a previously scheduled appointment with a potential client. Believe it or not the litigant won the case, because the surgeon’s malpractice insurer settled out of court.


Thus, if we rid the system of the multilayered, business oriented HMOs, promote entrepreneurship, encourage workers to invest in health savings accounts and purchase catastrophic insurance, each one paid for by non-taxable dollars coming from an employer who had previously sent that same amount of money to a HMO, if we insist that pharmaceutical companies reduce their overhead by eliminating counterproductive advertising, if we further insist that our legislators bring about tort reform and return medicine to its pre-1965 state of free enterprise with a consumer (patient) driven cost structure, then quality, consumer friendly and affordable health care will be the result for those who are insured as well as those who are not.