by Carol A. Westbrook
Do you really need a dozen pills a day to keep you alive, feeling well, and happy? Can you even afford them? Is it possible that the combination of meds that you are taking is making you feel worse, not better? Are you using up all of your sick leave and vacation time to attend multiple doctors' visits? Are you paying way much out of pocket for office visits and pharmacy co-pays, in spite of the fact that you have very good insurance? If this applies to you, then read on.
I am not referring to those of you with serious or chronic medical conditions, such as cancer, diabetes, and heart disease, who really do need those life-saving medicines and frequent clinic visits. I am referring here to the average healthy adult, who has no major medical problems, yet is taking perhaps twice as many prescription drugs and seeing multiple doctors 3 – 4 times as often as he would have done ten or fifteen years ago. Is he any healthier for it?
There is no doubt that modern medical care has made a tremendous impact on keeping us healthy and alive. The average life expectancy has increased dramatically over the last half century, from about 67 years in 1950 to almost 78 years today, and those who live to age 65 can expect to have, on average, almost 18 additional years to live! Some of this is due to lifestyle changes but most of the gain is due to advances in medical care, especially in two areas: cardiac disease and infectious diseases, especially in the treatment of AIDS. Cancer survival is just starting to make an impact as well. But how much additional longevity can we expect to gain by piling even more medical care on healthy individuals?
Too much health care can lower rather than improve your quality of life, and possibly even shorten it. For example, women who are given estrogens to relieve menopause symptoms have a significant risk of breast cancer. Blood pressure medicines can lead to unrecognized fatigue and depression; the same can be seen with sleeping pills, muscle relaxants, and anti-anxiety meds. Unnecessary X-rays or scans can lead to unneeded biopsies, which might result in serious complications. Even yearly PSA screening for prostate cancer can harm more men than it helps. Testosterone supplements can result in dangerously high blood counts. And of course, the money you spend on medications can be substantial, and the extra time you spend going to an office visit cuts into your leisure time and your income–directly impacting your quality of life.
How do you, the patient, break this cycle? First, you have to understand its cause. I'm sure you won't be surprised by my answer, which is “money.” The “medical-industrial complex,” operates on a fee-for-service business concept, and the way to increase profits is to increase services.
In the not-too-distant past, a person would have one General Practitioner (GP) or Primary Care Physician (PCP) who oversaw his health care. The GP would triage emergencies, treat chronic conditions such as hypertension, anemia or diabetes, diagnose new conditions that need intervention, and, when needed, refer the patient to a specialist for a visit or two. Extremely efficient for the patient, and somewhat time-consuming for the physician who, of course, would be reimbursed for his time. But today, private insurance and the CMS (Center for Medicare and Medicaid), the federal oversight agency, set limits on what can be charged for clinic visits by a GP vs. a specialist, sets costs for procedures, limits the allowable length of a clinic visit, and determines what diagnoses will be covered and what won't. From an economic perspective, this payment system incentivizes multiple short doctor visits to specialists rather than one-stop shopping with a GP. The resultant fragmentation of health care leads to more treatment, more medication, and poor coordination of care (see “The Bystander Effect in Medical Care: Why do I have so many doctors not taking care of me?” May 20, 2013).
The paradigm has shifted from “one patient, one doctor, many diagnoses” to “one patient, many diagnoses, and a doctor for each diagnosis.” And with each new doctor comes a new set of medications, and many more return office visits, of which many are done by mid-level providers, that is, nurse practitioners or physician assistants. Mid-level providers tend to perpetuate the status quo; they can speed a patient quickly through a routine clinic visit, but may not have the medical expertise to diagnose new problems, further increasing referrals to specialists. The latest innovation in health care, electronic medical records, further perpetuate medical inertia by including no-brainer “check boxes” for return clinic visits, automatic prescription renewals, and referrals to other specialists in the system.
How can you, the patient, insure that you are getting only the amount of health care you need? It's not a good idea to stop medications on your own, and it can be intimidating to confront your doctor for advice on how to do with less of him! But if you are serious about cutting back on health care, start with the following steps:
1. Be familiar each medicine you are taking–its name, what it does, and what condition it is treating.
2. For each medication, do you still have the condition for which it was prescribed? If not, would the condition return if the medication were stopped? (Examples are hypertension, thyroid disease and diabetes). Was it prescribed for a short course of treatment that is completed, but no one bothered to discontinue the prescription? For example, if you were put on arthritis medication for a bad knee, and you subsequently had a knee replacement, the pain med should have been stopped.
3. Are you taking multiple medications for a single condition when perhaps one might suffice? Sometimes all that is needed are dose adjustments. For example, getting the correct dose of a blood pressure medication might require many re-checks and frequent dose changes, and it is easier for a provider to merely add a second or third pill.
4. Are some of your medications expensive, or have high co-pays? For each class of drug (e.g. antibiotics, sleeping pills, acid-reducers, cholesterol medication) your insurance company has a preferred choice. See if your doctor can switch to that one instead. You might need to ask your pharmacist, or call the insurance company directly, to get their list, and then ask the prescribing doctor if it's appropriate and, if so, to change the prescription (and cancel the other one).
5. How many doctors do you see regularly? In particular, how many specialists are you seeing and how often? Find out what is the purpose of any return visits they schedule, and whether some of this can be done by phone or electronic messaging. Or better yet, can the follow up be done by your PCP? Or has the problem been resolved and you are a victim of the “return to clinic” check box? You may have to make an extra visit to the specialist to get this information and end the relationship.
Once you get this information, here are some steps you can then take:
1. Discontinue as many medications as you can, or switch to acceptable, cheaper alternatives, with your doctor's assistance.
2. Review your personal list of prescribed medications, and compare it to the one in the medical record at your doctor's office. Remove all medications from the list that you are not actively taking, or that have already been discontinued, and make sure this is reflected in the medical record. And by all means, confirm that it is not on auto-renewal at your pharmacy.
3. Cut down the number of doctor's visit, once you have determined which specialists you need to see, and which one don't add anything to your health care.
4. Prioritize and simplify your ongoing medical care. Mid-level practitioners are great for maintenance of existing chronic conditions, but when a condition changes, or there is a new problem, insist on seeing the doctor instead. (Most of my inappropriate referrals come from mid-levels who are trying to solve a problem they don't have the training to solve.)
5. Ask your PCP to interpret and prioritize your visits to specialists, and for the specialist to discuss and coordinate your care with your PCP. If your PCP is not accessible or interested, consider finding another one.
6. Make use of electronic messaging, email, or phone calls when possible, to replace clinic visits.
7. Adopt lifestyle changes suggested by your doctor that might help you avoid taking additional medication, such as weight loss, exercise, smoking cessation, diet modification. If you go through with this, ask for feedback from your doctor, who should be willing to re-evaluate your meds and your health–after all, he suggested it.
Now let's turn the tables and see how difficult this can be for the doctor. When I see someone who is stuck in the web of medical inertia, I may say, “You have too many doctors and are taking too many pills. It's time to cut back on both.” I am often met with resistance. Surprisingly, many people prefer to continue on the way they are. They don't want to hear that they don't need all these medications, or that their symptoms are due to depression or anxiety. They would rather take a pill than stop smoking, or lose weight.
For the rest, I do my best to help. I'm reluctant to stop medications started by another doctor; however, I can offer to help review medications and diagnoses. I can contact the doctor and see if the medication is necessary. I'll help to find cheaper alternatives when I can. As a rule, I don't renew medications that I didn't originally prescribe. For patients whose condition I am managing, I'll try to do a lot of my follow up by email or messaging, taking advantage of the electronic record. Every little bit helps.
Cutting back on medical care is a slow process on an individual level, and we physicians are just as frustrated as you are with the excesses in the system. The situation is not going to be improved by more insurance, but by reform of the entire system–which is unlikely to happen in my lifetime unless patients get involved and start demanding a change.
When I brought up this topic with friends, I was amazed to find how many had stories to tell about their personal experience with excessive health care. Do you, too, want to make a change? Please feel free to share your stories here. Maybe we can start to make a difference.
The opinions expressed here are my own, and do not reflect those of my employer, Geisinger Health Systems.