Dollars and no sense

aka American ER Doc Gone Walkabout… 005

Beginning work at Launceston General Hospital in Tasmania, orientation really, I noticed a lot of things missing: places to sign my name.

For any given patient I’d sign: the completed chart note, perhaps a lab (sorry, pathology) and imaging slip, a prescription form (in triplicate – Ok, so that was weird), and a GP letter.

I didn’t have to sign (physically or electronically) multiple different “attestations”, I didn’t have to generate multiple different medically useless forms and charts for purposes solely related to legal protections and billing. The portion of my time spent on paperwork as opposed to the tasks of patient care was much smaller. Generally pretty delightful.

Simple stuff: writing a medication prescription. OK, a little cumbersome: first – find the damn prescription pad (full 8 1/2 by 11 inches – what’s that, about 22 by 28 cm?) – too big to stick in a pocket. Then, paste a printed patient “sticker” to each of the 3 copies. Then, press hard so all 3 copies come through.

But, here’s what’s cool – I don’t have to worry about whether the patient can actually buy the stuff! He walks to the hospital pharmacy and walks out with the medicine in hand!

Now, there’s a couple of situations in the US where that happens – the patient always gets the prescribed medicine, no matter the finances – the Indian Health Service hospital where I work. The US’s other major “socialist” health system – the Veterans’ system for retired military. For those who are fortunate enough to join, some private systems like Kaiser healthcare.

But, at the majority of the hospitals in the US, there is a major consideration: can my patient buy this stuff?

So, University Hospital has a cool EHR – Electronic Health Record, including electronic prescribing: click, click, click and out spits a completed prescription to sign (or, in some instances, is transmitted direct to pharmacy/chemist so that, theoretically, the medications are ready by the time the patient arrives).

Oh, and the personal security code that has to be entered – 79 characters including upper, lower, and middle case, special characters except for the not-too-special characters, and numbers totaling not more than 250, nor less than 275, and has to be changed every 90 hours – and 17 times more complex than the codes that I’d need to move a million dollars from one bank account to another.

Kinda nice – it cross checks allergies (if somebody once vomited taking codeine last century, they will forever be listed as “allergic” to every opioid in the book – some estimates are that 97% of the “flags” are false positives, but some are actually important), automatically fills in the dosages (that’s fine unless different dosages for different indications – think metronidazole, acyclovir, cephalexin – pretty easy to get onto cruise control, accept the default dosage, and pull the trigger to hit the wrong target), and many of the residents no longer have any idea what the dosage of simple drugs is.

But, let’s say that I want an antibiotic for a lung infection that covers the atypical pathogens – I could choose levofloxacin, azithromycin, or doxycycline – respectively, about $120, $40, $10 for a week. Many of our patients can’t afford, or would be very hard pushed to afford, choices number one and two (yes, I know that there are other very good reasons to avoid number one). If I click on levofloxacin, I might as well advise many of my patients to just take some paracetamol – he/she won’t be able to buy the levo anyway. So, in the US we spend a bit of time (hopefully) learning the relative costs of drugs, and then discussing with patients whether they will be able to afford the drugs, and the relative costs and benefits.

Someone should point out, and I agree, that even in a less profit-driven system, there is a great value in being aware of the relative costs of various treatment strategies.

Take Tamiflu/oseltamivir – about $80 at the local chemist (all these are USD, but we’re pretty close on exchange rate right now). First, you need to know that, unlike Australia, minimum wage is not really enough for people to live on – $7.25 an hour – often, with no health insurance whatsoever. So, if the best evidence suggests that oseltamivir shortens the duration of influenza (we’ll forget the prevention of severe disease and complications) by about a day, spending $80 for one day quicker back to work may be a very good economic decision for me at my rate of pay, but not a very good economic exchange for my $7.25 an hour patient (ignoring the value of just feeling better a day quicker). If minimum pay is $16 an hour, (I think that’s about right for Australia), then a day back at work is a good economic value for society for every patient – and, of course is a good economic value for each individual patient who’s getting the medication at some price less than $80.

Here’s an even more bizarre one in the US: With the change from fluorocarbon powered albuterol inhalers, to HFA inhalers, the price jumped from about $15 to $80 – out of range for many of our patients. A large local hospital caring for many indigent patients, forbid the ER staff from dispensing inhalers for patients to take home – $80 that would likely never be collected. But, some of the ER Docs were just nice guys and wanted their bronchospastic patients to feel better. Some of the ER Docs did a quick, back of the envelope calculation, and figured that if a few of the chronic asthmatics that weren’t able to buy an inhaler, had a couple extra ER visits per year, the economy of not dispensing inhalers would be overwhelmed by the cost of ER visits and admissions. So, the staff of the hospital now typically (with good evidence to support the practice) treats many of the patients with a couple puffs on the inhaler in the ED. The patient is then warned that he is not allowed to use the inhaler when he leaves the ER, so please deposit the (nearly) unused inhaler in a trash can on the way out the door. Wink, wink (hmm, not sure if that’s a technique used in Oz – to wink when you don’t really want a person to believe what you just said). Rarely is the trash basket found to overflow with discarded inhalers.

And, a merry Christmas to you all.

LITFL Editor’s note:

Check out previous installments of ‘American ER Doc Gone Walkabout‘:

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  1. Meg says

    Love reading your posts Rick. I must sheepishly admit that in my mind you’re the Bill Bryson of Healthcare!

    We’re spoilt in many ways in Australia, and price very rarely enters the equation. I work in Health Services Research, with a bunch of Health Economists, so my view on $ in healthcare is probably skewed anyway!

    I just wanted to share a personal anecdote that your post reminded me of. I have PCOS, and I remember visiting a very lovely Endocrinologist who suggested I give Metformin a go, but he apologised solemnly that as it was being prescribed for off-label use, I’d have to pay full price. Oh, ok. The irony of this didn’t hit me until I picked up the prescription at the chemist, and worked out that the entire year’s worth of drugs I’d received had cost me a grand total of $13.50, whereas his initial cosult cost me $260!! I didn’t receive an apology for that!

    And p.s, most other Aust. States do actually have EHRs and electronic prescribing. At the moment I’m surprised poor Tassie can afford pens. :-(

    • Rick Abbott says

      Thanks for the comment. It’s pretty painful for me to follow the Tassie news on the health finance situation there. From a distance, I can’t tell how much worse it is than it was last fall, but it sure sounds worse. We were really looking forward to opening the new ER and acute medical unit -- they would be a huge help with or without additional staffing. But, with the cuts coming down the pipe ??????????

      Yesterday’s news headline was 30 patients waiting for inpatient beds that didn’t exist -- boarding in the ER and the not yet fully open new AMU. ER Boarding for 2-3 days was pretty common while I was there, but not to that numerical extreme. And with cuts to staffing, it might resemble hospitals where I worked in Nepal where your family had to bring bed linens and food -- I hope not.
      Since LGH’s ER was largely staffed by locums -- mostly of the fly in/fly-out sort, all the political hullabaloo about payments to locums doctors has to be worrisome.
      Not knowing Tassie politics and finance very well, I don’t understand what sort of a political football this has become.