close up of a single pill

Summary: We hear a lot from doctors who see the problems of the health care system from a perspective that’s often surprisingly revelatory. Occasionally, we meet someone who’s a good doctor, writer and thinker all at the same time. Dr. David Voran is one; he wrote this for us about the problems his patients encounter in filling prescriptions, and he offers a solution.





If it was up to me … and somehow we could even begin to afford it … I’d schedule 30 minutes for each patient.  It takes so much longer to convince a patient they’d be healthier by no treatment for a common cold.  I’ve tried hard to do this, but can usually tell within the first minute of  conversation that they are here for an antibiotic or something to relieve their symptoms and nothing else will do, even though medicine often doesn’t have much to offer for this condition.  Even when I’m successful in convincing them to avoid medication, it’s not unusual to get a portal message a couple of days later that they’re no better and would I please send an antibiotic to XXXX pharmacy.

By way of introduction, I am an active Board Certified Family Practice physician, 20 years out from residency with administrative and non-clinical experience under my belt, who has chosen to return to the front lines of medicine for the sheer pleasure of the patient contact and gratification that come from direct patient contact.

My hope has been to leverage the administrative knowledge and existing technology to do whatever is necessary to make the contact meaningful, fruitful and pleasurable for both the patient and the physician.  In this light I’ve encouraged, welcomed, pushed and prodded patients to participate fully in their care, and tried to make the exam room and electronic portal experience a learning one for all of us.

What’s adding so much time now is that once the patient and I have come to an agreement on therapy, the battle begins: third-party payers who will not cover the therapy or  recommended medication, or second
tier as opposed to first-tier, and the $20 difference in copay for the better treatment is too expensive for the patient.

I have spent the better part of an hour trying to find the one medication on that patient’s plan that will actually work.  Unfortunately the person on the other end of the phone cannot tell me, as they usually are just following a script.

There’s just way too much friction because the patient isn’t the buyer. There are so many shades of gray and intermediaries that want to control both the patient and physician in order to meet their needs.  The patient-physician agreements are becoming less and less important, as neither the patient nor I, the physician, are truly aware of all of the financial implications of those decisions.

Patients are just as frustrated as me when their plan will refuse to cover a treatment or honor the voucher we provide them. Other times they get frustrated that they got nothing for the spent time and money to visit me when I recommend no treatment is best.  They didn’t come to me for that.  They just like something to “make this go away,” when we physicians, who have access to just about everything know there’s nothing but time that’ll make “that” go away.

This struggle over medical therapy is way too costly … for everyone.  I’m coming to the conclusion that we could cut our nation’s healthcare bill in half if all medications would be over-the-counter.

We certainly would eliminate a large percentage of clinic visits because patients who know what they need could just bypass the expense of the office visit and make the purchase at the pharmacy.

We would have real patient-directed care and reserve the office visits for those who are in need of physician expertise and have the time to devote to their needs.

Looking back we in the world of medicine thought the world would end when H2 blockers used for acid reflux disease went over-the-counter.  Nothing of the sort happened, except a large percentage of gastrointestinal office visits vanished.

Right now some of the most toxic medications (acetaminophen, for example) are over-the-counter, and emergency rooms are not filled with damaged livers.  Most patients do a pretty good job of managing their medications if they are fully educated, and pharmacists are capable of doing that for medications.

It’s the doctor’s job to come up with the correct diagnosis, and maybe if we’d then give the patient a prescription that  contained only the diagnosis, then the patient and pharmacist would do an as good if not a better job of finding the right medication as any physician, don’t you agree?

Heck, if even all the narcotics were over the counter ,we could eliminate the DEA, and most of the illicit drug trade would vanish overnight as I doubt any of them could compete with Big Pharma.  The sales tax revenue on this alone could potentially fund all of health care.  The emergency room visits would be easier to manage because we’d know what was in that person’s system, whereas now it’s a guess that’s often lethal.

But we’re not there, for oh so many (mostly political, financial and religious) reasons.

On another front, the more I practice medicine the less certain I get, because we are really prevented from practicing medicine scientifically and there’s so much uncertainty.  Every disease exhibits itself differently at any course in the process and at some point shares symptoms with so many other diseases that it’s impractical to scientifically run all the “experiments” to rule out or in the one that’s actually causing the problem. This is especially true with many of the routine ailments seen in primary care that will often resolve within a few days.

As better technology allows us to do more outcomes-based research, we are now finding out that NO treatment for many of the common ones is actually the best treatment.  Heck, we’re now realizing that the health of the trillions of bacterial and fungal cells in and on our bodies is as important as our own human cells.  Prescribing antibiotics kills off many more good bacteria than the few bad ones we think we’re treating.  In the process we disrupt the body’s ecology and delay normal healing, or allow fungal and viral overgrowth extending the length of time before the symptoms resolve.

Compounding the problem:  we’re not able to prescribe the non-pharmacologic treatments and therapies that have been shown to work better than medications in many cases (spa sessions, steam rooms, physical therapy massages, yoga, etc.) because third-party payers will not cover them, and the patients certainly cannot afford the full retail cost. Even when these are prescribed, it’s stunning how often the patients will choose not to follow through with the recommended therapy.  In Germany and other countries, these therapies are the ones that are covered, as they are actually cheaper than medications.

So back to my solution.  Maybe everything should be over-the-counter and people should go to physicians only when they need our expertise and advice.

I wonder what the real free market would do the price of medications, therapies and … oops, my own fees.

Maybe this isn’t a good idea after all.

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Dr. David Voran is a family practice physician for Heartland Health in Platte City, Mo. This guest blog post was originally written as a conribution to the listserve of the Society for Participatory Medicine, of which Dr. Voran is a member, and then reworked for this blog. ClearHealthCosts is also a member of the group, a nonprofit supporting  “a cooperative model of health care that encourages and expects active involvement by all connected parties (patients, caregivers, healthcare professionals, etc.) as integral to the full continuum of care.”