Finding The Lost Art of Medicine (and myself) In the South Pacific: Service, Compassion and The Human Connection

Kevin R. Campbell, MD, FACC

CEO, PaceMateTM

Last year, I had the privilege of traveling to one of the most remote places on earth to provide medical care to natives on the island of Batiki (a small speck of land belonging to the nation of Fiji).  During that time, my life was in transition—I had just left clinical practice months prior due to burnout and a high degree of job dissatisfaction.  I was lost, lonely and in need of a reset.

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I signed on with a global charity—Sea Mercy—after learning about them through a connection with their founder, Richard Hackett on Twitter.  Sea Mercy provides medical relief to natives of islands throughout the South Pacific and relies on volunteers—doctors, nurses, dentists and boat captains—in order to reach come of the most remote places on earth. In early August 2017, I began my journey (both physically and emotionally) to help those in the greatest need.  After a 20+ hours of flight, I arrived in Suva Fiji and met a long-time colleague and friend Dr. Suzy Feigofsky who agreed to accompany me on the volunteer mission only months before. We spent a day catching up on each other’s lives and careers—family, work and all the rest—and then set out to meet our co-volunteers.

While many of Sea Mercy’s missions simply involve providing free healthcare to natives, this trip was a little different.  Rather than a small group of medical providers, our team consistent of a group of agricultural experts, teachers, psychologists and support staff. Known as the RISE (Remote Island Soils Education) program, the overall goal was to assist villagers in reclaiming soils for agricultural purposes so that they may become self-sustaining and produce a product that would allow for economic growth.  As a medical team our job was to not only provide healthcare for all of the island natives but to also provide medical support for the large team of volunteers.

On the day of departure, we met a group of native Fijian sailors and boarded a restored, original Fijian sailing vessel.  While the journey was scheduled to be a 3-hour sail, the weather had other ideas.  Once we left the security of the protected harbor on the mainland, we quickly encountered very rough seas and high winds.  We did not know until afterwards, but the sail from Suva to Batiki is one of the roughest passages in all of the Pacific.  Swells rose to 15 ft and winds continued to build to nearly 20 knots. It began to rain and most of our team became saturated, cold, seasick and afraid.  After hours of trying to make headway, we ultimately turned back (under darkness) and found a neighboring island where we could escape the high seas and wind.  The inhabitants there gave us food and shelter and we all were honestly thankful to be alive.  Even though I was scared, physically miserable and unsure of what was next, I felt more alive, and more present in the moment than I had felt in years.  While I was unaware at the time, I had already had begun a personal transformation—in my past life, I always “sweated the small stuff” and I always “missed out on the moments”.  This was just the beginning for me.

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After a couple of days of recovery and waiting for calmer seas, we made another attempt to reach our destination of Batiki.  We were able to make safe passage and we were warmly greeted by the natives of Batiki upon our arrival.  Men, women and children all waded into the water to help us ashore—all singing and thanking us with hugs and handshakes.  We were immediately ushered into a village gathering place where we were invited to take part in a traditional Fijian “welcoming ceremony” reserved for very special guests.  My first impression of the people of Batiki was their unwavering happiness and their love for one another and for a very simple life.  The accommodations were basic on Batiki—no running water, no electricity.  Homes varied from wooden structures to open air lean-to’s.  BUT EVERYONE WAS HAPPY WITH WHAT THEY HAD.   We were taken in by various families and welcomed into their homes in the village of Mua where we would live and work alongside the villagers during our two weeks on the island.

The next day, we began setting up our Village clinic.  The local nurse was incredibly friendly and resourceful and was very happy to see us.  We immediately went to work—patients began to show up and we quickly found ourselves flooded with patients.  In fact, the entire primary school showed up all at once.  Dr Suzy was immediately engaged with the children—allowing each one to listen to their own hearts with her stethoscope. Adults of all ages came in and before we knew it, we had diagnosed diabetes, hypertension, lupus, neurofibromatosis and a retinal detachment.  I had no EMR, no front desk staff, no insurance company and no hospital administrators interrupting my day.  My time was solely and completely devoted to my patients.  It was EXHILARATING.  That evening, I cried.  I am not even sure why—I just knew that I was happy and fulfilled and that I was doing good work.  I could not wait to go back to the clinic the next day.

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Clinic continued on at a more easygoing pace over the coming days.  We got to know families and gained an understanding of what challenges they faced every day.  One particular day, Dr Suzy and I split up in an effort to see villagers in multiple locations on the island.  I made house calls, while Dr Suzy and a team of volunteers hiked across the island to the village of .  This particular village was decimated by Cyclone Winston in 2016 and had not yet been rebuilt.  I was charged with making “house calls” to see the less mobile residents of Batiki. While I cannot speak directly to the moving experience that Dr Suzy had while visiting Naigani, I was amazed at the stories she told upon her return—stories of life and death and survival, fears of losing children in the flooding and wind….we will leave that for her to tell on another day.  As for me, I was able to gain a real appreciation for how little the people of Batiki really have.  When I entered the home of my house-call patients, I was able to see firsthand what every day was like.  Few possessions, limited clothing and no modern conveniences.  However, each patient had a story to tell.  Elderly patients living with the sequelae of strokes, crippling orthopedic injuries, chronic disease—but all faced every day with a smile.  I was invited into each home with a smile and a warm and welcoming “Bula” (hello in Fijian). No one complained, but all were clearly grateful that we were there.  Some of my patients just wanted to talk and learn about Western culture. Others wanted to tell me about their kids, and their life on the islands. Interestingly, not a single native mentioned wanting to leave Batiki—and no one wanted any of the things that all of us would deem a basic necessity.

Each night, Suzy and I would chat and share our experiences from the day. As each day went by, I felt myself changing.  I was becoming more aware of the little moments that mean so much.  While I missed my family and friends at home, I became aware of a connection with the villagers with whom I now lived.  Some nights, after work, we would all sit together (volunteers and villagers) after dinner, when the sun had set, and play cards, talk, listen to music and drink Kava….Now that was another VERY unique experience.  Kava is a local tradition and is a drink that is derived from the Kava root.  It has mystical properties and is a mild sedative. Villagers treat the drink with a sacred reverence and it is consumed as part of a Kava ceremony.  It became a way for the villagers—and the foreigners—to bond.

Days continued on with lots to do on the island and soon we developed a daily routine.  But, as my time on the island came to an end, I began to realize what is RIGHT with medicine on Batiki—it was akin to being an old country doctor to a small rural town. I was part of something far bigger than myself.  Medicine was about the patient, the family, the ties to the town or village.  There was no pressure to do more in less time, no insurance company, no EMR and billing and coding.  All there was were PEOPLE.  People who needed my help.  People who found happiness in so little.  People who became my friends and (in some cases) my family.

As Suzy and I sailed away and prepared to go back to America, I was filled with emotion.  I was not the same person that arrived on the island—I never would be again.  Even with all my faults and shortcomings, I had done something good.  Something much bigger and more important than achieving an academic promotion, a first authored article in the New England Journal of Medicine or a bigger and better job. I had finally REALLY made a difference. For the first time I really understood what it is to be a doctor and to truly serve others.  I was no longer lost.  I was clear in my path forward.

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Months have passed now, and I long for the warmth of the people of the South Pacific.  I miss their smiles and their laughter.  Batiki and Fiji calls to you and once you have been there, you will always feel as if something is missing back home.  Fortunately, I am headed back in just a few weeks.  Dr Suzy and I will be sailing to another group of islands know as the Southern Lau.  This time we will live on a 47 foot catamaran with 6 other volunteers and sail from island to island hoping once again to make a difference—in the lives of the villagers and in our own lives as well…..

 

Note:  If you would like to participate in a future trip with SeaMercy, please reach out to myself, Dr Suzy or visit www.SeaMercy.org for more information.

 

 

 

 

Back To Basics in Healthcare:  Barbershops, High Blood Pressure and Better Outcomes

Kevin R. Campbell, MD, FACC

CEO PaceMate

We spend more money per capita in the United States on Healthcare as a percentage of GDP (Gross Domestic Product) than any other industrialized nation in the world. Yet our clinical outcomes are no better than the average (and worse than many countries that spend far less than we do).  Our system is far more complex than others, much more expensive and often difficult to access.  Many patients struggle to engage and partner with a healthcare provider and the logistics of attending a visit with a physician can be difficult for the working poor, those with families and others with multiple obligations and roles to play in the family.

This past week at the American College of Cardiology Annual Scientific Sessions, one of the most important clinical trials in decades was presented.  The trial did not involve a new expensive drug or a new expensive test or surgery.  It simply examined how outcomes improved when patients were engaged around a particular chronic disease on their own turf.

In the study, researchers from Cedars Sinai in Los Angeles found that if they  counseled patients and actually had pharmacists take medicines to black males in their local barbershops, that they had a much more significant reduction in blood pressure as compared to those who did not receive the same service.  Published in the New England Journal of Medicine, the trial involved over 300 African American patients who were entered into one of two study groups–either an intensive counseling and treatment program with pharmacists (conducted at the local barbershop) or a second group that received lifestyle modification encouragement (such as seeing their doctor regularly) by the barbers on duty.   Upon completion of the study, a huge difference in blood pressure reduction was seen between the groups with 65% of the men in the pharmacist led group meeting blood pressure guidelines as compared to only 11% in the control group.  The significance of this study is compounded by data from the American Heart Association that makes it clear that black males have a disproportionately high risk for high blood pressure related complications such as heart attack and stroke.  We also know that medication compliance in hypertension among black males is much lower as compared to other demographics.  Moreover, black males are far too underrepresented in clinical trials in hypertension.
Why Is This Trial So Impactful?

Blood pressure is the silent killer.  Treatment of blood pressure should be individualized and requires a commitment from both doctor and patient.  Our healthcare system often makes it difficult for patients to bond with their providers.  Doctor’s offices can be intimidating places and many Americans do not feel comfortable going to a traditional medical setting.  By coming to the men in an environment where they are comfortable—such as a barbershop—healthcare providers can make a bigger impact.  In addition, when men are treated in a local environment with their friends, they are more likely to feel a sense of accountability for compliance.  Most significantly, however, this trial shows us that we can spend far less money and realize a significant impact when it comes to the treatment of very common diseases such as high blood pressure.  Doctors and patients MUST get back to basics when it comes to healthcare.  Making a connection and developing a relationship is vital to success.  Rather than expecting patients to come to a healthcare facility, we must work to provide more convenient touch points—such as telemedicine, mobile health and….barbershops.

What is Next?

This study should serve as a wake-up call to doctors, patients, politicians and those that determine how healthcare is delivered in the United States.  We must focus more on the patient—take medicine where they are—we should NOT always force patients to come to big healthcare systems.  WE must make sure that physicians are encouraged to reach out to patients and not confined to a clinic or hospital.  It is vital that we spend the time to better understand our patients–why they feel more comfortable in certain settings.  One size does not fit all–cultural differences, socio-economic status, and personal beliefs can have a great impact on who benefits to treatment in a particular environment and by a particular provider.  Most importantly, this study proves that it does not take expensive tests, expensive medicines or therapies to make an enormous IMPACT.  It is time to step back and put patients first—if that means going to a Barbershop to deliver care—then that is what we MUST do.

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Trump, Sanjay Gupta and The “Goldwater Rule” :The Fallout From the President’s Latest Health Report

Kevin R. Campbell, MD, FACC

CEO, PaceMate

This past week, President Trump’s physician released his first full medical evaluation as President.  What has in the past been a routine event with a few questions asked in the daily White House press briefing turned into a 90-minute circus with physician journalists such as Dr. Sanjay Gupta of CNN making sweeping diagnoses from afar.  A basic tenet of the practice of medicine is that in order to make a diagnosis you must establish a doctor-patient relationship and have seen and examined the patient.  In fact, prescribing medications or making diagnoses without an interaction with a patient violates the rules of most state and local medical boards throughout the United States.  Why then does the press (and even Physicians who are active in the media) insist on making uninformed and misinformed medical diagnoses when it comes to President Trump?

The mainstream media has used the President’s annual physical report as another tool for furthering a particular political agenda.  While I certainly do not agree with all of Mr. Trump’s policies, behaviors and decisions, I do not think that perturbing the facts associated with his health and making sweeping, broad statements about his health status are an appropriate means for political gain.  In fact, it serves to only demonstrate the desperation seen among Democrats and liberals throughout the country.

What did the President’s Yearly Physical Reveal About his Cardiovascular Health?

President Trump underwent an extensive evaluation by the White House physician (who, of note, was appointed by President Obama) and this included a history, a physical exam and several diagnostic tests.  The results of the exam and all of the tests have been made public and I have personally read through the entire document—but that does not mean I am qualified to make any diagnosis—I have never seen the patient and personally evaluated him.  Sir William Osler, one of the founders of modern medicine often said “if you listen to the patient long enough they will tell you what they have”—emphasizing the importance of the history and physical exam in making a diagnosis.

Mr Trump appears to have mild obesity (his BMI or body mass index is 30.1 and above 30 is considered to be obese).  He also has an elevated total cholesterol at 223 and a LDL (bad cholesterol) of 129.  Current guidelines suggest that we should use a total cholesterol of 200 and an LDL of less than 100 as a treatment goal.  Mr Trump also underwent extensive cardiovascular testing including a stress echocardiogram (ultrasound of the heart) which showed an absolutely normal result—no evidence of blockages, normal heart structures and chamber sizes and normal valves.

Sanjay Gupta’s Diagnosis from Afar

Minutes after the White House press briefing where all of Mr. Trump’s health data were made public and available to the press, Dr. Gupta stated on LIVE television that “President Trump has heart disease”.  In reality, heart disease is a complex diagnosis that relies on the consideration of risk factors—such as male sex, high blood pressure, high cholesterol, diabetes, obesity, family history and others—just to name a few.  In the case of President Trump, he does have risk factors for heart disease including the fact that he is a man and that he has high cholesterol.  However, he had a normal stress echocardiogram test—a test that evaluates the presence of any significant heart artery blockages and his cholesterol is being appropriately treated.  As mentioned above, the President is slightly overweight and needs to watch his diet and exercise more.  Technically, Dr Gupta is right—ALL of us have some amount of heart disease as evidenced by “fatty streaks” in our aorta even as children.  A fatty streak is the first sign of atherosclerotic disease and has been seen in very young children.  However, Dr. Gupta, who is a neurosurgeon by training and has no experience as a cardiologist, seems to have based the entirety of his comments on the result of a Calcium Score.  A calcium score is a test where a CT scan is done to determine if there is calcium in the coronary (Heart) arteries.  Some studies have indicated that an elevated calcium score can be predictive of the presence of coronary artery disease (blockages in the heart arteries).  According to many researchers, there is a paucity of randomized controlled prospective clinical trials about the accuracy and effectiveness of a calcium score in the prediction of heart disease.  There are data that do provide correlation but the widespread use of calcium scores in the evaluation of coronary artery disease has not yet been seen among US cardiologists.  In addition, calcium scores can be a useful tool to motivate patients and physicians to treat and modify risk factors for heart disease.  Calcium scores have also been shown to help with predictive models BUT are not diagnostic.  So, I would suggest that Dr Gupta, rather than making a sweeping statement such as “Donald Trump has heart disease” would be far more accurate by qualifying his remarks and reference the data concerning a calcium score rather than sensationalizing the President’s health during a package for CNN.

What is the Goldwater Rule?

The Goldwater rule was adopted by psychiatrists in 1973 after an incident in 1964 during the Presidential election in which a media outlet (Fact magazine) published a survey of thousands of psychiatrists in which they were asked if Barry Goldwater was psychologically fit to be President.  The Goldwater rule prohibits psychiatrists from offering an opinion about a patient they have never met or personally evaluated.  In many ways, the comments from Dr. Gupta and others are eerily similar to those made by the psychiatrists who never actually interviewed Mr. Goldwater.  For psychiatrists, this principle remains part of the American Psychiatric Association’s code of ethics even today (Section 7.3).  As physicians, we are to taught to assimilate the available data—through taking a patient history, performing a physical exam and evaluating laboratory data—in order to come up with a comprehensive diagnosis and treatment plan.  Making diagnoses without incorporating all data and actually examining the patient personally is simply irresponsible.  This not only applies to psychiatrists but should apply to ALL physicians specialties—even those of us who report in the media.

Is the President Healthy?

Bottom line, President Trump is healthy for a man his age.  If the President were my patient I would tell him the following:  You has risk factors for heart disease that must be modified—high cholesterol and obesity.

Currently, he is being treated for his cholesterol and his medications are being adjusted appropriately.  He does need to focus on making better dietary choices and he should lose some weight.  He must incorporate exercise into his daily routine and should have routine check ups to follow his progress.

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(Image via screenshot from MikeSheltonCartoons.com)

 

The CDC Bans Words “Science Based” and “Evidence Based”: Is this 2017 or 1984 and the Thought Police?

“The thought police would get him just the same. He had committed–would have committed, even if he had never set pen to paper–the essential crime that contained all others in itself. Thoughtcrime, they called it. Thoughtcrime was not a thing that could be concealed forever. You might dodge successfully for a while, even for years, but sooner or later they were bound to get you.”
– George Orwell, 1984, Book 1, Chapter 1

This week’s announcement in the Washington Post that the CDC has banned certain words in budget documents elicited outrage throughout the scientific community.  Science and innovation is dependent on the ability of researchers to ask novel questions and push the limits of current thinking.  Creativity, free expression and stoking controversy are an important part of the research process.  In Orwell’s 1984, censorship was the basis of the society and the Thought Police were a feared government agency.  It now appears that the current administration has enlisted Orwellian principles in the American scientific community.  If this is type of censorship is allowed to grow and expand, all of us will suffer—and patients and advancements in Medicine will suffer the most.

Banning Words and Thoughts

According to the Washington Post report, the following words have been banned in all budget communications at the CDC:

Fetus

Transgender

Diversity

Evidence Based

Vulnerable

Science Based

Entitlement

My first reaction to this report was disbelief.  REALLY? There is no way this could happen in modern America….We have come so far in the way we address questions in medicine and respond to public health issues.  From Zika to flu shots—from issues surrounding the treatment of transgender people to ways in which we can better serve underserved populations—science is blind and researchers should be dedicated to improving patient outcomes irrespective of political rhetoric.

However, after the publication of the repot in the Post, the division of Health and Human Services pushed back quickly and argued that the CDC and HHS remains committed to the use of scientific evidence to guide their recommendations for health policy.  Other Federal spokespeople have admitted that the reason for the “banned words” was to help expedite the budgeting process in Congress.  By avoiding certain words in budgetary documents, the agency leadership felt that it would be easier to get their budgetary requests through a Republican-controlled Congress.

For me, none of this really holds water.  Censorship—either direct or indirect—has no place in a government agency dedicated to science and the advancement and development of public health related policy.  As a Duke trained cardiologist, I have always been taught that the BEST way to treat patients is to use the best available scientific evidence from randomized controlled clinical trials (RCTs) in conjunction with clinical judgement to diagnoses and treat my patients.  Politics and censorship has never played a role in the way in which I practice medicine.

How Censorship Can Affect Science?

If allowed, censorship can stifle new advancements in Medicine.  Imagine a world in which Jonas Salk was not allowed to develop a Polio vaccine—or a world in which researchers were not allowed to develop a treatment for the AIDS virus—hundreds of thousands of people all over the world would suffer and die.  Much of our research funding comes from government agencies such as the National Institute of Health (NIH) and public health policy is also set by multiple government agencies including the FDA and the CDC.  IF we allow censorship, then the grant approval process and funding of research projects may be politically motivated.

It’s Time for Action

Politics has no place in science.  Science is neither Republican or Democrat—science is HUMAN and transcends race, gender and religion.  Science is all about passion, compassion, drive and innovation.  Science brings people together—politics divide us.  While HHS has now pushed back at the Washington Post report, the seeds of censorship in medicine have been planted.  As physicians, researchers, scientists and patients we cannot allow this type of behavior to be swept under the carpet.  All of us have a responsibility to express our outrage—reach out to your representatives in Congress today.  As for me, I will be in Washington DC this week to express mine on behalf of all physician scientists and patients.  For my colleagues in Medicine I implore you all:  Continue to innovate—continue to ask the hard questions—continue to think independently—Let’s all stay a step ahead of the “Thought Police” in our nation’s capital.

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CVS, Aetna and REM: It’s The End Of The {Healthcare} World As We Know it

This week, it was announced that two of the largest players in the American healthcare market have agreed to merge in a deal worth nearly 70 billion dollars.  This merger represents a departure from the traditional way in which doctors, patients, insurers and pharmacists have interacted for decades.  In the past, insurers and pharmacies have existed in separate silos.  As I discussed in a recent Op Ed, this old system was far from perfect.  Pharmacy benefit managers (PBMs) have taken advantage of patients, doctors and drug manufacturers and have served to raise the cost of medicines through demanding kickbacks known as “rebates”.  As bad as PBMs have been for healthcare, this new merger may actually be WORSE.  Now, mergers such as the CVS/Aetna deal will essentially bring the “Soprano-like” PBMs in house.  In addition, in the last several years, CVS has ventured into the healthcare provider market as well—staffing primary care “clinics” with pharmacists and nurse practitioners in retail stores (note the glaring absences of physicians in the CVS care model).  While CVS argues that the combination of a health insurance company and a pharmacy (that provides primary care services) will streamline patient care and lower costs, I believe it is likely to do just the opposite.

What IS the Likely  Impact of the Insurance Company/Pharmacy/Clinical Services Mega Store on Healthcare?

If this merger is allowed to proceed, all players (except for the mega CVS/Aetna conglomerate) in the US healthcare system will suffer negative consequences.

  1. Diminished Choice

Currently, many patients have limited access to drugs due to the role in which PBMs play in negotiating prices and determining what is on “formulary”.  This less than transparent process basically involves a system of bids from manufacturers where the highest bidder (for a rebate that is pocketed by the PBM) wins the preferred formulary status.  In addition, the PBMs can require patients to deal with a process of “step therapy” where they are forced to use less expensive (and potentially less effective drugs) than originally prescribed by their physician prior to being allowed to take the intended therapy.  If this acquisition is allowed to proceed, we will see even less choice.  Now, an insurer (who is motivated financially to prohibit access to more expensive therapies) will be partnered with a pharmacy who can potentially decide to only stock certain medications.  Price fixing may become the norm—if you are an Aetna customer, you may be only allowed to purchase your medications from CVS—even if there are cheaper options for you elsewhere.

  1. Rising Costs

When there is less competition, the consumer always suffers.  If we allow CVS and Aetna to merge, we are likely to see costs rise.  Healthcare consumers will not be allowed to shop around for less costly purchasing options.  I foresee a system where Aetna is able to dictate that ALL covered medications must be purchased from CVS.  If

  1. The Demise of the Doctor Patient Relationship

Medicine is defined by the way in which doctors and patients interact.  Trust is built over years of interactions—not in a minute clinic.  By removing the physician from the healthcare equation (as this merger is likely to do), patients will no longer be able to bond with a provider who can help them make difficult healthcare choices as they age.  Minute clinic staff tends to be more transient that physicians that work in long standing practices and medical groups.  While minute clinics can certainly be a great way to triage and treat simple, common primary care issues such as colds and flu, it is not a great venue for long term care of chronic disease.  Highly trained physicians who have completed between 3 and 10 years of Residency and Fellowship training AFTER the completion of their medical degrees are better equipped to make difficult diagnoses and manage complex diseases over time.  As a for profit entity, CVS is focused on cost containment—and Nurse Practitioners are far cheaper staff than board certified physicians.  In an ideal world, NPs and physicians work together and co-manage patients as each professional brings a unique perspective and a unique skill set to the clinical arena.

  1. Poorer Outcomes

When we focus purely on the economics of healthcare rather than evidence based medicine for therapy choice, outcomes will most certainly be less favorable.  If the CVS/Aetna merger is allowed to proceed, I expect all clinical decisions by CVS minute clinic staff will be based on treatment protocols and algorithms that are developed to contain cost.  Let’s be realistic—CVS and Aetna are in this to make money for their executives and their stockholders—the patient is really not their top priority.  Care delivered only by a Nurse Practitioner in a minute clinic is not the same as the care delivered by a Residency and/or Fellowship trained physician in a continuity clinic.

Ultimately, it is my hope that regulatory bodies in Washington DC will recognize this planned acquisition for what it is—an assault on the way in which medicine is practiced in the United States.  We continue to allow for profit corporations to dominate the decision making when it comes to healthcare policy.  WE must act to change this paradigm and PUT PATIENTS FIRST.  As Michael Stipe of the rock band R.E.M. wrote in his song, “world serves its own needs , don’t mis-serve your own needs”  If we do not act, this merger will be the first of many and will likely be “The End of  The {Healthcare} World As We Know It”

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The “Sopranos” of The Pharmaceutical Industry: Pharmacy Benefit Managers (PBMs) and How THEY Drive Costs UP.

Kevin R. Campbell, MD, FACC

CEO, PaceMate

Today, the New York Times reported that drug companies, insurers and pharmacies may “team up” to create effective monopolies.  Company executives argue that this would be better for patients and would improve care and outcomes—however, nothing could be further than the truth.  These conglomerates would further limit access and drive up costs.

Many patients and physicians have found frustration when attempting to prescribe a particular medication for a particular condition.  Often only certain drugs are “on formulary” (which means they are on contract) at a particular institution.  In the world of drug prices and availability, pharmacy benefit managers or PBMs serve as intermediaries between health plans, manufacturers and pharmacies.  PBMs are companies—such as Express Scripts, CVS CareMark and others–that are hired by health care plans and tasked with determine what drugs are available in a certain plan and which covered patients have access.  According to Forbes, Express Scripts, the leader in PBM market share generated 101 billion dollars in 2015.

How The PBM Mafia Works

Most PBM decision makers have absolutely NO medical training and have no idea how or why a particular therapy works.  They are simply there to manage cost—AND to fatten their own wallets during the process.  For every drug transaction, PBMs receive BOTH a reimbursement fee as well as an administrative fee.  In addition, when PBMs place a particular drug on formulary, they receive rebates and more fees from manufacturers which are NOT passed on to the consumer.  PBMs operate in a world with little oversight and even less transparency.  In other words, PBMs are middle men who are paid on both sides of the transaction—similar to the way in which Tony Soprano and his Captains ran their garbage business in New Jersey.

PBMs claim to drive down costs in healthcare by negotiating discounts, managing formularies to obtain rebates, encouraging generics and non specialty medications as well as increasing the use of their own mail order pharmacies.  In reality, however, PBMs actually drive costs up by using their “middle man” position to increase their own profits.  They work to negotiate contracts with drug manufacturers, health plans and pharmacies that maximize THEIR profits at expense of patients and physicians.  PBMs rely on a shady business maneuver known as “spread pricing”—which is the difference between what PBM charges a health plan for a certain drug and what it reimburses a pharmacy for dispensing it.  The PBM, in turn, is able to increase its margins as neither the health plan or pharmacy has any idea what the other is paid.  PBMs have a great deal of power to determine how YOU, the patient, is treated by your physician through determining tiers of drugs, formularies and preferred drugs.  One would think that efficacy, safety and actual DATA would determine which drugs get “preferred” status—but in the PBM world, its all about which drugs pay the best REBATES.  (Sound familiar? Remember Tony Soprano and all of the bribery, intimidation and other misdeeds? Similar to Tony’s “businesses”, every year, there is a bidding war among manufacturers and the company with the largest rebate (chunk of money to be paid to the PBM) always gets the preferred tier.

How Does This Affect Doctors and Patients?

Once a formulary is set, PBMs work to make it difficult to deviate from its tiers of offerings.  This can have a substantial impact on the doctor-patient relationship and can impact the way patients are treated.  For example, most PBMs put “step edits” in place in order to force physicians and patients to go through a series of preferred drugs prior to getting the drug that the physician originally intended for the patient.  This can result in unwanted side effects and significant delays in treatment.  If a PBM decides to switch to another drug mid year (which is almost always due to a more profitable contract with a different manufacturer), patients are forced to give up a stable therapy for a non-medical reason.  This can lead to disruption in therapy and negative patient outcomes.  The PBM system often stifles innovation as it makes it much harder for new drugs and biosimilar drugs to enter the market.  This can also lead to a non-acceptable lag in getting new therapies to the patients who need them most.  Ultimately, the PBM system and rebates related to PBM profits incentivizes higher drug prices—the higher the list price, the higher the rebate to the PBM.

What Can Be Done?

First of all, we must shed light on the activities of the PBMs and expose them for the mobsters that they are.  We must educate the public, patients, physicians and our legislators in Washington.  While healthcare reform seems unlikely at this time, Congress could act to limit the power and price gouging associated with PBM activities.  Transparency must be mandated—we should all be able to see the flow of cash between manufacturers, PBMs and pharmacies and identify areas of abuse.  In addition, transparency would allow prescribers to see exactly what each prescription really does cost.  Most importantly, we must allow doctors to use the drugs that are best indicated for their patients based on scientific data—NOT based on what generates the most profit for PBM executives.

Acknowledgments:  I would like to thank Dr. Madelaine Feldman–a practicing rheumatologist in New Orleans, Louisiana and leader in the fight against PBMs for her assistance in researching this particular piece.

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(photo via screenshot, HBO, The Sopranos)

 

 

 

 

 

 

Calling A Code Blue on the US Healthcare Reform Initiative:  My Visit to Capitol Hill

Kevin R. Campbell, MD, FACC

 

In the past month, I made yet another trip to Washington DC in order to make the case for meaningful healthcare reform.  While Congress continues to play partisan politics, patients and doctors continue to suffer. According to the Mayo Clinic, physician burnout is at an all-time high with nearly 50% of all US physicians reporting experiencing the symptoms of burnout in the last 3 years.  The Journal of the American Medical Association (JAMA) reported in 2015 that 30% of young physicians had symptoms of depression or suicidal ideations.  In fact, Suicide accounts for 26% of deaths in physicians ages 25-39 as compared to 11% of deaths in individuals of the same age in the general population.  Physicians are leaving practice at an alarming rate, with a shortage of over 100K physicians expected in the next decade. For patients, frustrations continue to mount.  Rising premiums, diminished choice (only one choice in nearly 23% of counties in the US and only 1 or 2 choices in 41%), and limited access have patients scrambling for their basic healthcare needs.  Medicaid expansion has not happened in over 1/3 of the States and many are left uninsured—millions more are underinsured.  Medicine continues to focus on the treatment of disease rather than on prevention. Patients are not getting proven screening therapies and many cannot afford necessary medication due to rising costs.   Clearly, something MUST be done.  Healthcare in the US is on the verge of a major collapse—poor care, poor access and likely physician shortages are looming.

Dr. Campbell Goes to Washington

I began making phone calls about a month before my visit in order to set up meetings with key Congressional influencers and leaders.  I was able to secure a few meetings and set off for DC.  On arrival on Capitol Hill, I was amazed by the general lack of interest in the healthcare debate (other than when cameras are rolling for the mainstream media).  On the day I entered the Rayburn Building (which houses most of the House of Representatives offices), there was a long line of people and politicians were buzzing around in the hallways—all due to more hearings on Russia and our election as well as President Trump’s tax proposal announcement—almost no one was interested in discussing healthcare.  I was able to secure meetings with a few Congressional offices and staff, including the Deputy Whip, Patrick McHenry from North Carolina.  I was able to meet with Congressman McHenry’s team and spent nearly an hour going over issues with healthcare.  They listened, took notes, and promised to follow up in the coming weeks.  They seemed truly interested and empathized with the plight of patients throughout the United States.  I also met with staff from Vern Buchanan’s (R-Florida) office and shared more of my concerns. Mr Buchannan sits on the Ways and Means Committee and is influential in discussions concerning healthcare expenditures and funding of healthcare related programs.   Interestingly, both of the Congressional staffs that I met with seemed genuinely surprised about my report of the “real” state of healthcare, particularly when I discussed issues of billing, reimbursement for physicians and the cost of drugs and medical devices.  I really think that many of our Congressmen and women are not adequately informed about healthcare related issues because they do not have to deal with the system in the same way that doctors and the average American patient have to on a daily basis.

Healthcare and Congress, On Life Support

I really believe that there is little hope for saving the US healthcare system during the next 4 years.  After more than 7 years of criticizing the ACA and campaigning on promises to repeal and replace, the Republicans have little to offer.  One would think that during the two Obama terms, the Republicans could have been working on a viable replacement plan—but clearly they have not.  In Medicine, we are always taught to be prepared, to be able to be flexible, and respond to unforeseen circumstances.  We meticulously plan our treatment, or surgical approach and our next steps.  Congress, after winning majorities in both Houses and also taking the White House, has shown a lack of preparation to actually govern—particularly when it comes to healthcare.  The Democrats, always simply satisfied with the status quo, refuse to admit that Obamacare is not viable in the long term and have not put forward ANY plans to address its failings.  Most of their energy has been put in to thwarting any legislation put forward by the opposition.  The Republicans, due to bitter infighting within the party, have crafted piecemeal replacement plans that are likely to show no real improvement—in short, these plans simply “rearrange deck chairs on the Titanic”.

What MUST Happen Now?

In the hospital, when a CODE BLUE is called, all available staff rush to the bedside of a patient who is in distress.  In most cases this means the initiation of CPR of cardio pulmonary resuscitation and any necessary heroic measures are employed in order to save the patient’s life. Any indecision or any delay in treatment can result in death for the patient.  However, if the CODE team works in concert, with a single goal (of saving the patient’s life), comes together quickly and effectively, a positive outcome is far more likely.   It is now time to call a CODE BLUE on healthcare in Washington DC.  We must demand that both Houses of Congress focus on real, meaningful healthcare reform.  Any delay, much like with a patient who is in distress, will lead to disaster and ultimately, death.  Not only for healthcare as we know it, but ultiamtely for doctors and patients as well.