The Complete Patient

I knew my latest BusinessWeek.com column about Elizabeth Vaughan, the North Carolina physician who opted out of the whole insurance routine, represented some kind of emerging trend. I just didn't realize how immediately emerging...till a physician friend referred me to a magazine put out by the American Academy of Family Physicians, "Family Practice Management". The February issue devotes four articles to profiling family practice docs who are targeting cash-only patients and moving away from the hassle (and lower fees) of insurance and HMO networks.

What intrigued me even more than the four profiles was a commentary by the magazine's editor, Robert Edsall, in which he raises the question: "...what would happen - and how would insurers, employers and the government respond - if a significant minority or even a majority of practices went cash only? Is that even possible?"

I think I can answer his question with some confidence. The insurers would fight the move tooth-and-nail because they would see it for what it is: an attempt by doctors to go around the insurers to market directly to patients. As I point out in my BusinessWeek article, insurers are acting as marketers for physicians. In return for bringing business to the doctors, the insurers pay doctors at wholesale, and re-sell their services at retail (via their insurance premiums). Business-wise doctors recognize that they can do much better financially if they can attract patients whom the physicians can charge retail rates.

Employers would welcome the trend. Employers hate paying all or part of health insurance premiums, and for good reason: it's a huge, and fast-rising, expense, and their competitors in China, India, Germany, and England aren't saddled with this expense; the government pays, or else patients pay. Here is a comment from a speech by the CEO of Wal-Mart Stores Inc. to the National Governors Association a few days ago: "The soaring cost of health care in American cannot be sustained over the long term by any business that offers health benefits to its employees."

I suspect the government would back the insurance companies, since the government hates change. Moreover, the insurance companies are big givers to senators, representatives, and the President.

It's all part of a power struggle. For the past half century, the insurers have been winning the battle, hands down. But there's nothing that says physicians can't fight back, and win. After all, isn't it the opportunity for such cat-and-dog fights that makes America great?

The studies on nutritional supplements are coming fast and furious, it seems. (Just a coincidence?) Now it's the turn of glucosamine and chondroitin sulfate to treat osteoarthritis, in the current New England Journal of Medicine. And once again, the results appear muddled. Overall, the glucosamine and chondroitin sulfate didn't do significantly better than a placebo, while Celebrex, the Big Pharma drug, did do significantly better...except (there's always the exception, it seems) patients with moderate to severe cases seemed to experience a fair amount of pain relief from the supplements.

If you thought you might find clarity in the media, forget it. The New York Times headlines its summary, "Supplements Fail to Stop Arthritis Pain, Study Says". The Wall Street Journal's headline: "Supplements May Help Relieve Moderate to Severe Knee Pain". (To access article, go to www.WSJ.com and search under "supplements".) The Times seems to have a real problem with subsets in a survey that contradict results from entire sample.

Glucosamine and chondroitin are so widely used that I suspect most of us know someone who is getting relief from the supplements. My wife, Jean, has been taking them for a couple of years, and has gained relief from mild arthritis pain in her knees. In fact, when she's run out a couple times, the pain has returned within a week of discontinuing the supplements. An M.D. I know has recommended the supplements to many of his patients, who  similarly experience relief.

Bottom line: try the supplements before resorting to Celebrex, and risking all the side effects any Big Pharma drug entails. You may be pleasantly surprised, and one of the "exceptions."

Big Pharma is great at creating "magical" solutions for our problems. It promises cures for the diseases that scare us so much,  and solutions for our everyday irritations. I won't get into the fact that Big Pharma hasn't come very far in curing such diseases as cancer and Alzheimers. Its latest solution for the irritations of life is a new class of sleeping pill.

On the sleeping pill front, public radio did an excellent program today on the business of sleep. One item that stands out: a Big Pharma company spent $200 million promoting a sleeping pill last year, on which it generated something in excess of $300 million of revenue. But it isn't the one year's revenue it is interested in--it's the long-term revenue that comes from creating addicts out of consumers who become dependent on the pills.

One excellent outcome of the program is letting people know that there are much less costly, and less risky, ways of dealing with sleep problems than the addiction route.

I hate to keep returning to The New York Times, but it is doing more than other mainstream publications in trying to make sense of recent studies about nutritional supplements and diet. On Sunday, it attempted to assess the implications of recent studies of women suggesting that calcium and vitamin D didn't reduce hip fractures, and that low-fat diets didn't reduce cancer.

Typical of mainstream media, it agonized over the absence of a clearcut answer.  Assuming the answer is "no," it wondered whether women should abandon low-fat diets and return to bacon cheeseburgers.

But what if the answers aren't clearcut? What if individuals differ enough, and the potential combinations yielding benefits are more complicated than "low-fat" vs "high-fat"? What if environmental toxins are more of a factor than any study has yet shown, irrespective of the supplements one takes? That is something the mainstream media haven't figured out how to deal with.

At least they do allow that more studies will likely be needed to obtain answers. I suspect lots more studies.

A few days ago it was saw palmetto that was being torched. And before that, echinachea, vitamin E, and St. John's Wort. Once again, though, if you read past the headlines saying women over 50 gain no benefit in preventing osteoporosis or colorectal cancer by taking calcium and vitamin D, you begin to wonder about the headlines.

Buried in the New York Times article about the study is the information that among women over 60 in the study, there was a 21% reduction in hip fractures among the group taking the supplements. The article then goes on to suggest that statistical differences within subgroups are nearly meaningless. Yet this subgroup happened to consist of 10,000 women taking supplements, and another 10,000 taking placebos. And wouldn't you tend to expect women over 60 to be most prone to the effects of osteoporosis?

And the Women's Health Initiative, sponsor of the study, itself says in its conclusion, "We know that the use of these supplements for an average of 7 years slows loss of bone density and may help protect against hip fractures." Doesn't sound like "no clear benefit" as stated in the New York Times article.

Beyond all that, there's nothing in the articles or study summary about the vagaries of nutritional supplements. For example, calcium and vitamin D can be absorbed differently by different people, depending on their forms. Vitamin D as "cholecalciferol" is generally thought to be absorbed best by the body, but it isn't clear what form the women in the study used.

More certainly to come in this arena, so stay tuned.