March 20th, 2008 by Dr. Val Jones in News
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About a year ago I had the chance to speak with the founder of Micromedex Inc. about his views on the potential differences between brand name and generic drugs. He expressed some concern about the allergenic potential of filler substances in both brand name and generic drugs, and I was quite interested in the clinical impact of these differences.
Just recently, an article in the LA Times has shed more light on the debate about drug equivalency, and my fellow bloggers Abel Pharmboy and Joseph (at Corpus Callosum) have summarized the issues very well. As it turns out, the FDA allows for a fairly broad interpretation of equivalency when it comes to the rate at which the bioactive ingredients are released into the bloodstream.
To use an imperfect analogy – let’s pretend that water is the drug you’re taking. You can access water from a drinking fountain or a fire hydrant, and the amount you get in your mouth all at once may vary between the two sources, though the water itself is the same “drug.” This is the sort of difference that exists between some generic drugs and their brand name “equivalents.” The rate at which they get into your system can differ by as much as 36% and still be considered identical drugs by the FDA.
Now, imagine that someone offered you water in a paper cup or in a water balloon. The water’s container (analogous to the “inert filler” used to hold the medicine together in a pill or liquid form) is made of different substances (paper versus latex) and doesn’t make that much of a difference in quenching your thirst… unless you’re allergic to latex.
So there are true differences between generic and brand name drugs, though most of the time these differences are not clinically important. But in those special circumstances where people are allergic to fillers, or need a constant or regular concentration of their drug in the bloodstream, generic vs. brand name really does matter.
However, I think that in general generic drugs are terrific and have substantially reduced costs and increased access for millions of people. It is reasonable to save money by switching to generic drugs when possible. It is also important to resist the urge to believe that higher drug prices guarantee more effective products. In a recent JAMA article it was demonstrated that people believed that pain medication placebos were more effective if they were told that they were also more expensive.
But, if you’re one of those patients who tried switching to a generic drug and found it less effective – don’t let your doctor tell you you’re imagining things. There could be a real difference that you need to explore.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 19th, 2008 by Dr. Val Jones in True Stories
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My father-in-law just had his gallbladder removed. There was a small complication with the surgery (due to pus leakage from the gallbladder) and a laparoscopic procedure needed to become an open surgery. He did fine and is recovering nicely. I’m very glad that his surgeons did what they needed to do to get that infected organ out of his body safely.
However, his very minor “complication” reminded me of a gallbladder horror story that I once heard about from a surgeon friend of mine. I have changed many details of this story to protect the privacy of the patient (whom I’ve never met), but I think it’s important to talk about the event, especially in light of the recent surgical errors being discussed in the blogosphere.
A young man had suffered from gallstone “attacks” and was scheduled for a very routine laparoscopic cholecystectomy. It was the end of the day, and the surgeon scheduled to do the procedure had been working a 24 hour shift, and was quite tired and irritable. He wanted to do the procedure as quickly as possible and get home to dinner and an early night’s rest. The nursing staff remained quiet as he fumed and sputtered, preparing the patient with a betadine scrub and letting them know that he wanted to set a new record for speed of gallbladder removal.
The small incisions were made and some trocars were inserted so that the belly could be inflated and a camera and instruments inserted through the holes. The surgeon went to work quickly dissecting and preparing to remove the offending organ. In his haste, however, one of the instruments fell out of the skin incision. Enraged, he asked for a new one and began inserting a trocar blindly into the skin incision without guiding it with the camera. He had some difficulty getting it in, and began applying more and more pressure to puncture its way through to the middle of the abdomen. Exhausted, he jabbed it back inside with a final twist, inserted the instrument and then picked up the camera to continue the procedure.
Confusion gave way to terror as the internal camera showed the belly filling up rapidly with arterial blood. The surgeon had punctured the abdominal aorta during the trocar reinsertion. This was a surgical emergency. Ashamed of his mistake he decided to try to handle this himself, opening the belly wide to cross clamp the aorta and repair it without the patient needing to know about his near brush with death. Unfortunately, the repair took far longer than the surgeon expected, and blood flow to the legs was compromised for several hours (causing internal clots). Many units of blood were ordered for transfusion, nearly draining the blood bank of its reserves.
Tragically, although the young man did survive the surgery, he required an eventual double amputation of his legs. And all this after what he thought would be a simple gallbladder removal.
This is a sobering example of how serious any surgery can be, and why it’s so important for every procedure to be handled with the utmost patience and care. Many people have told me that surgeons don’t need to have a “good personality” because they mostly deal with anesthetized patients, but I think that this is a shallow view. A surgeon’s character is uniquely tied to his or her performance, and if they have a propensity towards a short fuse, it could result in tragic errors like this one. If you are considering surgery, you should feel comfortable with your surgeon’s style and personality. Don’t be afraid to get a second opinion or seek out a different surgeon if something doesn’t seem right. Your life may depend on it.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 18th, 2008 by Dr. Val Jones in Health Policy
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As you may have heard, the City of San Francisco has decided to provide access to healthcare for all its inhabitants, including about 82,000 uninsured and undocumented workers. How will they pay for this? Time magazine reports:
Annual funding for the $203 million program will come from re-routed city funds (including $104 million that now goes toward uninsured care via emergency rooms and clinics), business contributions and individual enrollment fees, which will be income-adjusted.
Businesses with more than 20 employees are required by law to pay for health coverage for employees. This has hit the restaurant industry hard, and the fallout is reported in a recent article in an AHIP newsletter:
Phan pays as much as half the cost of health insurance for about 100 full-time employees. Another 100 part-timers get no coverage. He estimates that his healthcare costs will jump by 67% to $500,000 this year with the new program.
Such “a constant assault” makes “every chef I talk to not want to open another restaurant in San Francisco,” he said.
And owners of smaller places, with fewer than 20 employees and exempt from the healthcare requirement, say that it’s become too costly to expand in the city, even when business is booming.
“We will always have 18 [employees] now,” vowed Anna Weinberg, a co-owner of South, a 50-seat restaurant featuring Australian cuisine that opened in October. Weinberg plans to open her next eatery on the Westside of Los Angeles.
In order to comply with the new ordinance (which is being appealed and may even go to the Supreme Court), employers may do any of the following:
There are essentially five ways to satisfy the health care expenditure requirement of the ordinance: (1) make a contribution on behalf of the employee to a health savings account; (2) reimburse an employee directly for his or her out-of-pocket expenses; (3) purchase health care coverage for an employee through a third party; (4) directly provide health coverage to an employee by means of a self-insured program; or (5) make a payment to the City of San Francisco, which will then, in turn, use the payments to fund a program for all uninsured City residents.
While I sympathize with the concept of having healthcare for all, I wonder if San Francisco’s approach will backfire? When businesses can no longer afford to employ workers, unemployment skyrockets, industries leave town, and those who are left will have to pay even more to shoulder the burden. San Francisco is one of the wealthiest cities in the United States, and may survive longer than other cities with these new laws, but in the end I think we might see a mass exodus and the beginning of a local economic depression.
Are the restaurant owners a collective “canary in a coal mine,” or do you think the San Francisco healthcare solution is the lesser of the evils? Will the nation learn something important from this bold initiative?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 16th, 2008 by Dr. Val Jones in Humor, Medblogger Shout Outs
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My friend Mindy Roberts is a mommy blogger extraordinaire. In fact she was one of the very first in this genre – and is author of themommyblog.com.
I’ve shamelessly stolen excerpts from her book “Mommy Confidential: Adventures form the Wonderbelly of Motherhood” for my blog readers. And now, she has created an entire website for kiddie quotes. If your kids or grandkids have said something funny, please share it with the world at PearSoup. Or if you’d just like to return to your own wonder years… take a look at what kids are saying these days. Here are some quotes that I liked a lot:
“Mommy, are you sure you remember how to make a baby?”
— Terrel, 4
“If I plant this eggplant will it grow eggs for us?”
— Spencer, 4
“Whew, that sure was undignified!”
— Ryan, 3
(After running away from the vacuum cleaner)
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 13th, 2008 by Dr. Val Jones in News
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There have been some recent news stories about a new type of identity theft – people (presumably without health insurance) are able to get coverage by stealing your insurance information and posing as you during hospital visits. Alternatively, hospital employees can steal your information and sell it on the black market. Some people estimate that medical identity theft may account for up to 3% of all identity theft in the US. Yikes! I even blogged about an infuriating previous encounter I had with a medical identity thief in the inner city.
I had my identity stolen once about 7 years ago – it was a very sobering experience. One day my credit card company called me to ask about some suspicious activity… which led to tracing events and purchases with eventual police involvement, further investigations, culminating in a Nigerian crime ring apprehended in upstate New York. Wild stuff. But I still use credit cards.
I would hate to think that medical identify theft could stall our good faith efforts at streamlining the healthcare experience. Sharing information securely and safely is a critical piece of the continuity of care and quality puzzle. Will there be hackers? Probably. Will some people be victimized? No doubt. But the vast majority of folks (if appropriate precautions are taken) will benefit from having all their providers on the same page, their medications, tests and procedures de-duped, and accurate records available for loved ones in emergencies.
The elephant in the room is whether or not people will be excluded from insurance coverage based on their electronic health records. To me, that’s scarier than potential medical identity theft, and probably the largest reason why patients are hesitant to digitize their health information (i.e. use PHRs).
What do you think about this elephant? Is there anything that can be done about him?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
