A problem with medicine that ObamaCare won’t solve

I spent four hours at my Mom’s yesterday trying to organize her medicines.  I am more gray now than I was before.  My son, who was with me, kept saying “This is insane.  This is insane.”

The insanity operated at a lot of levels.  Some of the insanity comes about because my mother likes her medicines (my son calculated that she takes approximately 800 pills per month, or 9,600 pills per year), and because she takes them on a schedule of her own devising, entirely separate from what’s on the pill bottles.  This meant that, after I’d organized her 800 pills for the month according to the actual prescription, she announced that half the drugs in the boxes shouldn’t there because she doesn’t follow the prescription.  At this point, my son physically restrained me from leaping across the table and strangling her.  (I exaggerate.  He actually gave me a kiss and a hug when he realized I was getting very frustrated.)

Another aspect of the insanity is the uncoordinated medical care my mom gets.  I’m used to Kaiser, which operates on a centralized model.  The doctors all plug into the same computer system, so whether I go to an Ear, Nose & Throat specialist, a Generalist, or Dermatologist, each has access to my medical records, and can readily see what drugs, if any, I’m taking, and what treatments, if any, I’m getting. This means that I don’t get overlapping, duplicative, or conflicting drugs or treatments.  Also, because it’s not fee for service, Kaiser has an interest in efficient medicine, which includes cutting down on unnecessary pills.  Market competition, however, ensures that Kaiser doesn’t take this philosophy so far that it deprives its customers of necessary treatment.

My mother, however, refuses to make the market choice to go to Kaiser.  In the days before medicine went insane, Kaiser did not pay very well compared to private practice, and private practice doctors weren’t yet driven broke and mad by malpractice, managed care, and government regulation.  Medicine’s best and brightest, therefore, did not usually end up at Kaiser.  As medicine changed, though, with private practice doctors overwhelmed by the costs of malpractice insurance, and buried under managed care, government, and insurance requirements, Kaiser suddenly started looking very good.  As a result, in San Francisco and Marin, Kaiser provides some of the highest quality medical care available, all for one monthly cost, plus low medicine co-pays.

My mother’s traditional care is the exact opposite of the Kaiser model.  Although she ostensibly has a geriatric doctor who oversees and coordinates everything, the reality is that she goes to several private practice offices, none of which are connected to her geriatric doctor or to each other.  Heart Specialist A has no idea what medicine Endocrinologist B is giving my mom.  Theoretically, each sends an email to Geriatric Specialist C, apprising him of the situation, but it’s like the old game of telephone, where the message breaks down.  The situation is made worse by my mom’s personality, since she distrusts one of her geriatric doctors and, as I said, ends up taking the medicines to suit herself anyway.

The real problem, though, comes at the pill level.  Because my mom orders from different pharmacies, and because these pharmacies order drugs from different manufacturers, all of her pills look different from each other.  For a given prescription, Pharmacy X might send a purple 50 mg capsule, with instructions to take one at bedtime; Pharmacy Y might send a red/white 50 mg capsule, with instructions to take one at bedtime; and Pharmacy Z might send blue 25 mg capsules, with the instruction to take two at bedtime.  Regardless of cause, the result is that, from month to month, my mother, a very visual person, has no idea what her medicine is supposed to look like and often has no idea how many pills to take.

Pharmacy labels are also a problem:  They’re sooooo small.  The only company I know that has taken this issue seriously is Target, which specifically markets clear, large print, straightforward labels.  Unfortunately, my mother, a stubborn person, refuses the Target option.

The end result of this is that the labels my mom gets vary from pharmacy to pharmacy.  All, though, offer small writing, with the relevant information appearing almost randomly on the labels.  Between my mom’s macular degeneration and my middle aged eyes, both of us were struggling to compare the pills before us to the laundry list of medicines she takes.  Fortunately, my son was there to read the multi-digit numbers printed in microscopic font on the drugs themselves.

I don’t see how ObamaCare can fix this problem.  To begin with, it cannot change my mom’s psychology.  She’s going to do things the hard way regardless.  Second of all, you cannot replicate Kaiser on a nationwide scale.  If Kaiser were suddenly a government owned and operated business, with no competition, it would simply be Britain’s National Health Service, which is running out of money.  Read the British papers and you’re daily assaulted with stories of massive drug and treatment denials.

The lack of competition is the real killer (literally) for NHS patients.  In response to stories about old or sick people are left in hallways to die, deprived of food or drink, or otherwise abused, or about treatments and medicine denied, the British government organizes commissions that, after several years, release studies and make recommendations, which recommendations then slowly wend their way through the political process and are occasionally passed, only to be ignored by the hospitals, which have no competition.

ObamaCare doesn’t improve the confusing pill situation either.  There is no ObamaCare mandate requiring that all drugs look the same, regardless of manufacturer.  Nor can one force all pharmacies in a region to buy from one manufacturer, or require a single pharmacy to stick with one manufacturer regardless of price needs.  The best pill solution is a market-based solution, although Target is so far the only one that has seen the light.

As it is, I’m just going to keep adding the gray hairs, and dragging my son along to aid in my emotional stability.

Cross-posted at Right Wing News

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  • Oldflyer

    Empathetic Book.
    Couple of thoughts.  Uncoordinated medicine is dangerous.  My brother died in a diabetic coma.  His oncologist gave him steroids as part of his ongoing treatment, while simultaneously his Primary Care gave him steroids to boost him up for a planned flight to visit us.  Boom! They later squabbled over who was at fault, but it was too late for him.   They were supposedly communicating and coordinating, but obviously not effectively.   (Full disclosure; he was already on a downward path because of multiple myeloma, diabetes and general poor health directly due to a destructive life style.)
    My pharmacy is my last line of defense.  They are good about resolving conflicts.  I trust them more than I do every day Drs.  I would certainly recommend that anyone use only one pharmacy for all Rx.
    My family in Orange County, Ca use Kaiser.  They were terrific with the premature twins.  Simply could not have asked for better care, from anyone, anywhere. They are at best adequate with the routine stuff.  Always start with the same old ineffective antibiotics for kid’s ear/throat infections unless the parents create a fuss.  Which sometimes helps the process, and sometimes not.  My wife and I have our battery of Drs, and we like to choose the ones we see; but, I do believe that will  soon be a relic of the past.  There is already a problem with the small practice being saturated and not available when you are actually sick and need to see someone–now.
    Oh, the good old days–or at least the seem good in retrospect.

  • http://ymarsakar.wordpress.com Ymarsakar

    Part of centralized government medicine is that they use propaganda to claim that by centrally locating information and decision making, they can do it better than all these distributed networks of people who don’t know what’s really going on in your medical history.

    The truth is, that’s not even a plus for government medicine because ObamaCare has all the VICES of centralized networks but NONE of the virtues. In fact, distributed private care networks have all the virtues of centralized and distributed networks, with only the vices of one or the other.

    Centralized agencies are supposed to be able to coordinate things well because they have access to the information and people required. In reality, they shop it out to a thousand different “doctors” and providers, because they’re too FING LAZY TO DO IT THEMSELVES.

    That’s basically it. Centralized organizations are of no worth when the central committe has a bunch of retarded murderers, euthanasia proponents, and greedy fracka punks.

    The Left truly is living in the dark ages. But even if they weren’t, they are going to make sure you do.

  • SADIE

    Bookworm, I am grayer just reading about the four hours.  It’s impossible to know if your mom is over or under medicated on any given day. She’s looking at the pills like they’re M&M’s and if she’s not in the ‘mood’ for the yellow or green one the pill sits.
     
     

  • http://ymarsakar.wordpress.com Ymarsakar

    people did that with anti-biotics too, Sadie. And ended up creating mutated strains of bacteria that anti-bacteria stuff no longer works. So if you or someone you know dies from an infection due to anti-bacterial non-effectiveness, you can think the layouts that said “I feel fine, I don’t need to take the full regiment proscribed”.

  • Gringo

    Even if one is not a pill-happy person, a lot of pills can be the result. When she died, my mother was juggling medications for three  chronic diseases: two  diseases she had had for decades  and the killer she had the last 8 years. Even with coordination among MDs, she was taking a lot of pills. I would estimate 15  a day.
     
    These were necessary medications. Without them she would have been dead twenty years before. The MDs took her as far as she could go.
    Even while her MDs did coordinating, and even while I could see the necessity for the pills,  the number of pills she took was still mind boggling to me.
     
    I have no advice for Book in that difficult situation. Only sympathy.

  • suek

    Not exactly on topic, but I ran across this link today:

    http://www.therealcuba.com/Page10.htm

    I figure your mom is taking about 28 pills a day. That’s insane. With that many pills, does she even need to eat?

    I’m lucky. Aside from a slight case of cancer some 20+ years ago, I’ve been in good health. No pills so far. Which is good – I’m not very good about taking pills – don’t like them. About the only thing I take are allergy pills – over the counter type – and even they’ve gone beyond their expiration date. But I still take them if I need to, which is probably about half a dozen times a year. Which is why they’re beyond their expiration date.

    It almost sounds like your mom _likes_ taking pills, and is managing things so that she gets more of them. Maybe gives her bragging rights? Or maybe just a coordinating/trust issue, as you theorize. Maybe she feels more in control…

    I think if I were you, I’d do a list of all the pills with the instructions, who prescribed them and why, and then copy and send to each one of her doctors. Would your mom feel like you were “telling” on her?

  • SADIE

    suek, good suggestion Pill, Who and Why. Read the link you shared. I wonder if Hugo is enjoying is top notch medical care ;)
     
    Bookworm,
    For what it’s worth a friend’s mom (currently nearing 90) entered independent living about 10 years ago. If she didn’t have a first name, we would have called her Stubborn. A fiercely independent woman (although we all knew that there were decisions and ‘oops’ moments that said otherwise). The facility where she resides, for a fee, will dispense all meds and after too many trips to the hospital literally and figuratively, this is exactly what the local son did – he made arrangements for all the meds to be a) removed from her apartment and b) managed by the facility.

  • Charles Martel

    As a person fiercely devoted to social justice, i.e., the elevation of everybody to the same level of material existence, I have been close to tears all day knowing that El Lider Hugo Chavez is ailing, and perhaps even near death. Thank Sky Fairy that brave Hugo is being tended in a Cuban hospital, which we know from Michael Moore offers this hemisphere’s highest level of medical care and expertise.

    I also thank Sky Fairy that our beloved president, a loving, self-effacing Christian man, is striving to the utmost of his great spirit and genius intellect to reconstruct the Cuban experiment here at home. !Que Viva Hugo! !Que Viva Barry Barack Hussein Sotero Obama!

  • SADIE

     
     
    “I’ve just learned about his illness; let’s hope it’s nothing trivial”
     
    -Irvin S. Cobb

  • Gringo

    Charles, if you are interested in more commentary on Thugo’s health issues, here are three English language blogs to check out.


    http://devilsexcrement.com/
     
    http://daniel-venezuela.blogspot.com/
     
    Also Caracas Chronicles. (2 link limit, I believe, so I do not include it as a link, but you can Google it)

  • abc

    The US has the most market-oriented system in the world, yet its health care costs double that of other developed countries that deliver equivalent care (e.g., France, Japan, Germany, Switzerland, Australia, et. al.).  The problem is most definitely NOT the lack of competition, but the problem is one of information asymmetry that causes there to be a NEGATIVE correlation between cost and outcome, as Atul Gawande has carefully and convincingly chronicled with facts and figures.  Conservatives point to the lack of funding as proof that Medicare is a bad system, but that confuses funding decisions with efficiency.  Medicare has seen cost inflation that is less than half that seen in the private sector, and the reason that HMOs exist in America is because American companies were tired of seeing so much fo their profit go to pay for worker health care.  While Congress underfunds EVERYTHING since politicians only get elected when they give the voter a too-good-to-be-true proposition, the reality is that if Congress were funding the private payor side of health care, the deficits would be much bigger.  Medicare delivers equivalent care at lower cost than the private sector, since it addresses the cost inflation head-on without limiting unnecessarily competition amongst suppliers.  That is, Medicare leverages the private market while addressing its inherent failures. 
     
    Bookworm selects data and selectively frames the problem to reach an erroneous conclusion.  The fact is that Target or Walmart aren’t dumb and haven’t been slow to see the light.  The reality is that drug companies have a lot of excessing pricing and margin to give the big pharmacies, so there is no incentive to make the costs on these products cheaper–although the Democratic push for greater generics has started to serve as an important offset.  Just not enough to address the many other examples of market failure within the US health care system.

  • http://bookwormroom.com Bookworm

    abc,

    I don’t recall mentioning costs as a problem.  I focused on (a) my mom’s own habits, (b) too many doctors with too little communication, (c) the fact that manufacturers don’t standardize the look of pills, and (d) confusing labels with small writing.  Yet you challenge post on cost grounds.  How did you arrive at that?

  • abc

    Because the problem with our health care system is skyrocketing costs that increase disproportionately relative to quality of outcomes, unlike in France, Germany, etc.  The problem is not communication levels of doctors, forgetfulness of the elderly, multicolored pills or 2-point font on medicine labels.  If you don’t know that, you don’t know much about the problem.

  • Danny Lemieux

    ABC “…yet its health care costs double that of other developed countries that deliver equivalent care”

    Numbers, please.

    Also include data on:

    1) equivalence of care (including survival statistics from cancer and heart disease).
    2) Full costs, meaning state subsidies included.
    3) Actual per-capita numbers for different countries. 
    4) Quality of care statistics (include infection rates in hospitals in different countries, such as British NHS and Canadian Health services).
     

  • http://ymarsakar.wordpress.com Ymarsakar

    Book, A thinks he has telepathy and can read the brain waves over the net. Humor him a bit on this. It’s funnier that way.

  • http://ymarsakar.wordpress.com Ymarsakar

    If you don’t know that, you don’t know much about the problem.

    John Kerry: “Do you KNOW who I AM?”

  • http://bookwormroom.com Bookworm

    Objection, abc — non-responsive.  I know that, to a hammer, everything is a nail, but the problem with my mom is indeed different colored pills and poorly labeled bottles.  The only way to circumvent that problem would be to stick her in a government run hospital, which would go strongly against her wishes, and then to watch her die from despair.  There are some things — such as old age — that don’t yield to government intervention.

  • SADIE

    There are some things — such as old age — that don’t yield to government intervention.
     
    I am glad I am not his elderly mother. That absence of pathos is pathetic.

  • abc

    Sadie, I have plenty of pathos.  However, Book is using a personal experience to attack health care reform in the US, noting that these problems don’t become solved under Obamacare.  There is nothing wrong with pointing out that such criticism is misplaced since the problems highlighted are rather trivial in the grand scheme of things, while the major problems, which are related to cost are being ignored.  This has nothing to do with lack of empathy for Book’s mother, but plenty of disagreement over the conclusions to be drawn from the post.  Such ad hominem arguments are counter-productive to understanding the key issues concerning health care,which should be the focus of concerned citizens.  Perhaps a little more pathos for those suffering under the failures of our health care system would be in order…

    Book, if the problems you cite were big enough, pharma companies could easily address them.  Apparently, the problem is not large.  Or there is a serious market failure here.  Either way, it is unclear that you are correct that there are only two solutions, the status quo or a government hospital.  Anyway, I stand by my earlier statement about cost.  It’s not about a hammer only seeing a nail.  It’s about numbers and their relative sizes.  Those that fail to pay heed to the numbers are doomed to talk nonsense.

    Danny, the World Health Organization has collected lots of data on this and has found that the US pays roughly double (expenditures as a percentage of GDP) on health care and receives outcomes that are inferior to France and other European countries.  You can quickly find their reports on the web, and they do compare costs on an apples to apples basis with all subsidies on both sides included. (for example:  http://healthpolicyandreform.nejm.org/?p=2610).  Some have criticized the figures snice the uninsured in this country skew down the overall outcomes.  But I would say that as long as those uninsured are part of the spectrum of American outcomes, then they ought to be included.  Other conservatives have argued that the US has better cancer outcomes for certain types of cancer, which is attributed to more liberal use of testing.  However, the cost of those tests is a fraction of the excess spending occuring under the US system, so that should not be an inherent limitation or weakness of the French or German systems.  In short, the US system is definitely not clearly better than elsewhere in the world, although we are paying so much more that it ought to be.  For more on this line of argument with data, see:  http://www.urban.org/uploadedpdf/411947_ushealthcare_quality.pdf

    Speaking of excessive costs in the US, here is a comparison of per cap health care spending in 2010, with data on the US and other developed countries:  http://www.creditloan.com/blog/2010/03/01/healthcare-costs-around-the-world/; http://www.nationmaster.com/graph/hea_tot_exp_on_hea_as_of_gdp-health-total-expenditure-gdp