As I sit behind a computer in my office today at the Physician’s “workstation”, I am baffled at the steady flow of Pharmaceutical representatives that flow into our office on a daily basis. Each rep comes in with a fancy glossy print detailing the data concerning their particular drug. My office is busy—patients are coming in and out and medical assistants are busy checking vitals and verifying medications (and of course, entering data into the computer system EMR). Yet the reps come in and stand at the workstation until someone acknowledges them. They stand, and stand—often distracting clinical staff. These reps are given a quota of “visits” they must make by their superiors. Many times they will arrive with their direct supervisor in tow—they are evaluated by the relationship they may (or may not have) with a group of physicians. But my time with each and every patient I see is limited due to the increased electronic medical record work that I must do—I feel bad for the reps (it is not their fault that they are placed in this role)—but Do I really have time to stop the endless flow of clinical work to speak to them? Does a Pharma rep actually provide any real value to me or to my patients? Would a “detail” presentation by any rep change my practice?
The Days of Yore
In the past, pharma reps were a source of “samples” that I could provide to my poorer patients who could not afford their meds. This was a real value—I depended on reps to provide these medications for my patients. In the days of print only access to journals, I may not have been as current with the medical literature. Reps would often come in and discuss breaking trial news that I had not yet had time to read about. Often they would discuss upcoming trials and plans for the future. We would have spirited “academic” debates over drugs, trial design and outcomes or endpoints. When you were unable to attend scientific meetings, the pharma rep would often be able to summarize the latest trials after they were released.
Now, my institution no longer allows “samples” to be left, and honestly, if I need a drug rep to share the latest data with me then I am not doing my job as a physician. Online access to immediate data from trials upon their release makes “keeping current” much easier. Social Media and other digital tools make it possible to attend national academic meetings such as the American Heart Association annual scientific session or the American College of Cardiology meetings allow everyone to be virtually present for ground breaking presentations of Late Breaking Clinical Trials.
Don’t get me wrong, there is nothing wrong with the people who choose to be pharma reps—many are smart, classy, well-meaning folks. However, there is a lot wrong with the antiquated pharma rep sales model in today’s world. Modern technology and easy access to data allows physicians to keep up with the latest clinical trials. Pharmaceutical detailing by reps is not very helpful—it is scripted and based solely on what the FDA allows them to say (think on label vs off label). Reps are not allowed to talk about upcoming trials or discuss any off label applications.
What’s the Answer?
Drug prices in the United States are far too high. Pharma will argue (rightfully so) that the costs of research and development (as well as marketing) drive those costs. However, I think that there are ways to lower costs without sacrificing R and D. I would argue that a restructuring of the pharma “sales force” would save significant dollars. I would also argue that making the FDA approval process more streamlined, faster and more agile would also lower costs. The current Congress is working on the “Cures Act” that will address some of the issues associated with the FDA process. Ultimately, I think that pharma must adjust to the way medicine is now practiced. There is no role for the pharmaceutical representative in the office or hospital. These individuals have absolutely no bearing on my choice to prescribe a particular drug and do not contribute to my continuing medical education. Nearly 75% of all Americans go to the internet after a doctor’s visit. Almost all physicians can access the internet immediately from a smartphone or tablet. Pharma should move their marketing and sales efforts to the digital space exclusively. There is no role for in person physician-pharma rep interaction in medicine today. Use these dollars in better ways—fund patient assistance programs, improve treatments and fund clinical trials. Stop spending money on lunches for the office staff and on fancy packaging. Glossy detail cards are simply tossed in the trash as soon as the representative leaves the building. Focus more on patients. The days of the drug rep have come to an end.
As we enter year two of the Affordable Care Act, we have seen many issues arise during implementation. Through both executive order and executive memorandum, President Obama has unilaterally changed the law more than 100 times in order to advance his own political agenda. When it became important to publicize enrollment and increased coverage of the uninsured, the President and the ACA provided for an increased payment scale for patients with Medicaid. With the rapid increase of Medicaid insured patients due to the implementation of the ACA, the administration utilized the increased payments as an incentive to attract more physicians to participate in Medicaid programs. According to the New York Times, the ACA has resulted in the largest increase in Medicaid covered patients in history–now nearly 20% of all Americans are covered under this plan. Attracting physicians to cover Medicare patients has been critical in order to meet the demand for access to care and to adequately cover the newly insured. Now, unless changes are made this week, Medicaid reimbursements will be cut once again leaving many physicians to wonder if they can continue to treat the increasing numbers of Americans covered thru these programs.
Traditionally, Medicaid has reimbursed physicians at rates significantly lower than Medicare–making practices with large numbers of Medicaid patients financially non viable. As the ACA was rolled out, a provision provided for significantly better Medicaid payment rates to physicians in order to help provide larger networks of care for the newly insured. Now, there looms an automatic payment rate cut of nearly 43% for Medicaid payments to primary care physicians–many of these are the same physicians who agreed to expand Medicaid within their practices in order to meet demand. According to Forbes, traditional Medicaid reimbursement averages just 61% of Medicare reimbursement rates (which is often significantly lower than private insurance rates). In addition, many Medicaid patients require a disproportionate amount of time and resources from the office–doctors are caught between a “rock and a hard place”–between a moral obligation to treat these patients and a desire to avoid financial ruin. These patients tend to be sicker, have multiple medical problems and have suffered from a long time lack of preventive care.
Finances are not the only piece of the Medicaid puzzle. Government regulation and paperwork and processing often delays payments to physicians and impacts their ability to run a financially sound business. Interestingly, a study from 2013 published in Health Affairs suggested that while physicians welcomed an increase in reimbursement rates as incentive to treat Medicaid patients that quicker payment times, reduced paperwork and simplified administrative processes would also need to be a part of any type of reform. (of course, none of these items were included in the incentive package).
Many primary care physicians stepped up to answer the call for increasing coverage of Medicare patients when the ACA was initially rolled out. Now, these same physicians are contemplating the need to drop these patients from their clinics with the pending change in reimbursement. As mentioned above, in addition to lower reimbursement rates, the Medicaid program requires an enormous amount of administrative work in order to file claims and these claims are often paid very late–those running a small practice are forced with more work for less pay and often have to make difficult budgetary decisions in order to payroll for their staff each week. While the administration touts the swelling numbers of Medicaid covered patients–nearly 68 million currently–I suspect access to quality care will soon become an issue. Just as with every other manipulation of the ACA over the last two years, legacy and political agendas have taken precedent over what really should matter–providing quality medical care AND prompt, easy access to care for the formerly uninsured. In an effort to tout swelling numbers of “covered” Americans, the Obama administration has failed to anticipate the impact of short term financial incentives for primary care physicians to accept increasing numbers of Medicare patients. Even in states such as California, officials are bracing for a large number of physicians who have announced that they will likely drop out of Medicaid plans if the planned cuts are implemented as scheduled.
It is time for the Obama administration to stop playing political games with our healthcare. If the mission of the ACA is to provide affordable quality healthcare for all Americans, then we need to ensure that there are quality, dedicated physicians available to provide that care. The Medicaid “bait and switch” is just one example of our President’s shortsightedness and lack of connection to those dedicated physicians who work tirelessly to ensure that ALL patients have access to care (regardless of insurance type). It is my hope that the new Congress will engage with the physician community and find real solutions to the US healthcare crisis–and no longer allow the President to place his perceived legacy over the healthcare of those Americans who are in need.
Image adapted from The Peanuts comic strip by Charles Shultz
The practice of medicine and healthcare in general has become an electronic and increasingly mobile interaction. Patients are better informed, more engaged, more connected and have a much greater virtual presence. In fact, according to Pew Research data, the fastest growing demographic on Twitter are those who are in the 45-65 age bracket. Nearly 50% of all seniors engage online on a daily basis through at least one social media platform and many of these interactions and online engagements occur via mobile devices. Almost 75% of all adults go online within hours of attending a visit with their physician in order to gather more information about their particular medical problem. For healthcare providers—and for patients—the internet and mobile technology presents us all with wonderful opportunities to interact, engage, support and ultimately improve outcomes.
New connected devices and medical applications for mobile devices are on growing exponentially. The world responded favorably to the latest release of the iPhone 6 and the iOS8 operating system recently released by Apple. The new device has many interesting features but one in particular caught my eye early on. Apple has created a standard package for all iOS 8 devices that is called the Health Kit. This particular application allows a user to track calories, steps taken (similar to a pedometer), flights of stairs climbed and other customizable health related data points. These data can be organized into graphs and charts that allow users to track progress and adjust activity levels to achieve particular goals. More impressively, the device will allow other health related applications to organize data in the Health Kit as well. One of the biggest problems with medial applications in the past is that there has never been an easy place to organize, store, collect and view all of the data together. Moreover, this data is not easily shared with healthcare providers. The Health Kit and Apple may revolutionize this entire process of data collection, retrieval and sharing—Apple has partnered with a major electronic medical record service known as EPIC. Work is underway to allow the Health Kit data and applications to easily interact with the EPIC medical record. This would allow for easy downloads of health data during a face-to-face encounter with healthcare providers. Currently, most major hospitals and healthcare systems are moving to the EPIC platform. The data collected and downloaded at one location would subsequently be available to all providers in the system—portability of data allows for better care and less duplication of effort.
Much has been written about patient engagement and improved outcomes in the medical literature. I can think of no better way to improve engagement than through the use of real time health applications –these allow patients to receive real time feedback—both good and bad—and respond quickly in order to improve their overall health status. I think that this type of technology will only continue to grow. Apple plans to release the Apple Watch in early 2015. I expect that this will also be integrated with Health Kit and allow for the measurement of respiratory rate, heart rate, body temperature and other biologic measurements. As these tools continue to develop and applications grow, healthcare providers as well as patients must be receptive to their use. These technologies have the potential to allow clinicians to better assess patients between office visits and provide more directed and timely changes in therapy. Ultimately I believe these technologies will transform healthcare. As we continue to struggle with healthcare cost containment in the era of healthcare reform, the ability to shift care and routine interaction to mobile platforms may very well prove to be a critical piece of the puzzle.
This is an exciting time in medicine as well as in healthcare technology. Moving forward, I look to a day where biologic sensors collect data, relay data to mobile devices and then transmit information seamlessly to healthcare systems. The healthcare providers are alerted to any abnormalities and electronic responses are generated—those patients requiring timely in person visits can be identified and scheduled, while those that can be handled virtually can be managed quickly and effectively as well. Ultimately, our goal is to better manage disease and improve outcomes. I think that technologies such as the Health Kit and the Apple Watch are giant leaps forward and are just the beginning of a new age of virtual healthcare.
Posted in Doctor Patient Relationships, Healthcare Reform, Optimizing Patient Care, Outcomes
Tagged apple, Engagement, EPIC, healhcare, healthcare applications, medicine, patient care, technology