The Paradocs Podcast

How do PBMs (pharmacy benefit managers) pass on savings to themselves and leave patients and insurance companies holding the bill? It's hard to answer that question without first understanding what a PBM is, how they work, and what their role is in the pharmaceutical market. Unfortunately, the PBMs intentionally cloud what they really do in order to continue ripping off patients and insurance companies with unnecessarily high drug prices.

This week's episode is a longer interview I did as a guest on the Gray Matters Radio Podcast with Mike DeVine. He had me appear in February as part of his series exploring the US health care system and its many dysfunctions. In this episode we explored the problems with the pricing system, group purchasing, economic scarcity, and why things are just so darn expensive. Of course they all get answered and wrapped into a nice little bow at the end of the interview.

Only in medicine is discussing prices before providing care a revolutionary concept. Prices serve as an important signal to both providers and patients as to the relative scarcity of care. Whether that is time with a physician, time in the operating room, the cost of equipment necessary for procedures, or medications the price signal is important for both sides to understand the real cost of using resources.

How would you feel if someone who didn't know, was unfamiliar with your symptoms and story, and had never examined you dictated the way you were treated? Would you be upset if the people making those decisions were not specialists or maybe even had the same training as a physician? Unfortunately, this practice is very common today in every doctor's office in America and it is called prior authorization.

If there were a conventional treatment for a disease in a traditional medical practice that worked only 10% of the time or less - would anyone feel comfortable claiming it was a fantastic cure? I suspect not, yet those abysmal successful treatment numbers are present in some areas of the mental health arena when it comes to addiction treatment. However, you almost never hear about the failure of the 12 step programs or outpatient treatment plans and their high failure rate. Why is that?

Today, the topic physician burnout and looking at the numbers at who is suffering and what the causes are. Medscape published its 2019 Survey of Physician Burnout, Depression, & Suicide that dives deep into the demographics and causes of the phenomena. However, what was notably absent from the possible causes for burnout was financial matters. What effect does a high personal debt have on physician well being? And if it is a problem, how can you find your out of debt to improve your psyche as a physician?

I have spent a lot of time discussing innovative ways of delivering medical care on this show and it has primarily been based around primary care. However, those who are specialists who traditionally practiced using third party payors (Medicare, Medicaid, commercial) are also beginning to strike out on their own and switch to cash pay. The reason for this is that the cost of using insurance and the lack of access allows these specialists to find a market for the type of medicine they want to practice.

What is the difference between a first year medical student and a senior in college? A lot of debt and neither knows anything about medicine. Contrary to popular belief, medical students don't know the first thing about the health care system, how it is delivered in the United States, or what challenges face physicians in caring for their patients. So all of the popular opinions floating around in the general undergraduate student population are present upon their training.

For those who have encountered the health care system - the emergency room is the greatest mystery for charges. Although little of emergency care is truly emergency life threatening care (est. ~3%) the care is some of the most expensive in the hospital. Whether that it is imaging, laboratory, or professional services - patients and insurers are expected to pay the inflated costs. So how do we control costs and not break the bank for all of our patients when they are possibly at their most vulnerable?

If there is one thing patients and doctors agree about when it comes to primary care it's that it isn't properly working for either one. Doctors have too little time to spend with patients, can only address one or two problems at a time, and spend most of the little face time they get staring at a computer screen than at their patient.

When it comes to working, we all have different goals on what to accomplish during our careers. However, almost everyone anticipates on retirement as the way they end their professional life. The FIRE movement is one which emphasizes achieving your financial independence and retirement at a younger than traditional age. With careful planning and goals in place at a young age, you can achieve the goal of financial independence with more time to control your life without worrying about financing living. 

One of the tasks assigned to physicians, and certainly not a task one thinks of when entering medical school, is to verify death. The first time you declare someone dead - for me, it was as a first year resident in the ICU - is a weird feeling because of the finality of it. As with anything you do as a physician for the first time there is some uncertainty that you aren't "messing up." But you don't need to be a doctor to declare someone dead because anyone can tell when someone or something is dead, right?

Direct Primary Care (DPC) is starting to gain some steam and popularity with established physicians, residents, and medical students. Patients are also beginning to learn about this alternative to traditional insurance based care. Instead of copays, deductibles, and limited visits and times with the physicians - DPC works as a monthly fee with unlimited access to the physician.

Physician suicide is an epidemic. How else do you describe 400 physicians per year ending their own lives which is over twice the national average? Why do so many doctors feel that the only escape from their pain is suicide? How do we end this epidemic and begin to heal the healers?

We can all agree - outside of a few overpaid pharma CEOs - that the American Health Care system is too expensive. In fact, one could argue that the system of delivering health care in America is designed to cost the most possible without any parts that can check its growth. If you were to try and design a more costly and inefficient system I dare say you would be unsuccessful.