Dr. Malia Reckons

I am sorry to say this, and I need to move beyond the emotion, but right now, I feel bitter.

This year, I have not been able to get a small order of 150 influenza shots. In past years I have had a couple flu clinics for my own patients on Saturdays and Sundays when I gave out about half my shots. The other half was given during appointments with high-risk patients, those I scheduled in October and early November with diabetes, heart disease, lung disease, chronic kidney disease, etc. Anticipating the flu shots, and trying to help them get better value from one appointment and not waste time and energy, I plan such appointments many months ahead of time.

Now, in an effort to get the influenza vaccine to high risk populations early, before the H1N1 flu vaccine is more available, and lessening the risk of confusing the two, the seasonal flu shots were sent from manufacturers directly to companies that run community outreach programs and large pharmacies.

That, by itself, would not be a problem if I also could get a supply to offer my patients in my own office. But, this year is incredibly frustrating, and I, like many, many other primary care docs around the country, am not getting an order of flu shots.

Adding insult to injury, at least one pharmacy is letting patients schedule times for flu shots but they do not yet have a formal protocol for giving them and therefore have to get a formal approval from me to give the shots. I'm spending time every day explaining to patients about the hassles I have had trying to get flu shots, encouraging them to get the shots, and then asking them to find the community outreach programs and pharmacies where the shots are available.

Like so often happens in primary care, this is a situation where I am trying to work for the benefit of my patients but then others in the system are getting paid while I'm left empty handed. It is a business model with fundamental flaws.

Consider this: for my own patients, with whom I have long, on-going relationships, and for whose care I maintain malpractice insurance, I spend time and energy getting them to go to a pharmacist (a pharmacist!) of a large corporation to get a flu shot. And, I must wonder, what happens to my patients if they have severe reactions? A post-vaccination reaction will be dealt with by whom? The pharmacist? Or me? Who gets the phone call if there are questions after the vaccination?

I am bitter, but not proud of it. I can not get flu shots, but large corporations can. I have to encourage my patients to get the flu shots, but then someone else in healthcare will profit from my efforts.

Watch for other blog posts later about this, but here I present a major problem in the American system and primary care. Society has two trump cards that get thrown at primary docs depending on the situation and on what the powers-that-be need at one time or another. Either docs are told: "this health care stuff costs a lot of money, so you better run a good business model and focus on value for the patients," OR, when it serves other needs, we are told: "but doctor, don't you have a moral obligation for the welfare of your patients and to not think of care as a business?"

In the end, the system is making doctors who can't maintain the business model and are so burnt out they can't maintain the proper moral tone. In discussion groups among doctors working hard to make primary care better, I see this feeling again, and again. And I fear the general public does not understand the situation or what the doctors are feeling.

I'm sorry, but, right now, I'm bitter.

--Timothy Malia, MD

Last winter, a local supermarket pharmacy started offering free antibiotics. Many common antibiotics were included, and a prescription for up to 2-weeks worth could be gotten at no cost, not even a copay.

Besides getting the supermarket chain some good (free) publicity, I suspect the program got it extra business. Since the antibiotics in the offer tended to be the least expensive, the store likely made back the money, and then some, from folks buying other supermarket items while they waited.

At the time, I was interviewed about the program by a local newspaper. That article can be found at -- http://www.wickedlocal.com/mpnnow/towns/fairport/x1708113095/Wegmans-offering-free-antibiotics.

My feelings on giving free antibiotics are mixed. My thoughts turn to the economics of the program as well as the clinical risks involved. I wonder how doctors and patients should approach this issue. And if this is a sign of things to come in health care.

I do think the program is a good business decision for the large supermarket pharmacy. But, I also suspect it could hurt small, private pharmacies which may offer fine, personalized care and service but can not afford to match the no-charge medicines. I was quoted in the article:

“Those small businesses often offer personalized service that is convenient and local, and I believe many patients would benefit from just that kind of care and attention,” he said. “With the marketing of the low-cost and free prescriptions at the large-store pharmacies, I fear the small community pharmacies may lose business and patients unwittingly may lose a service they dearly need.”

Yet there are many patients who are helped financially with this program even if they are only saving a few dollars. Those with no insurance for medicines likely benefit the most.

But I also worry about the pressure on doctors and patients to make decisions based on the out-of-pocket costs of the prescription. Initially, when the program was to be short-term, I had a few patients request prescriptions they would hold in case they needed them after the program ended. I declined each time -- besides possible insurance fraud, I do not like antibiotics sitting around our medicine cabinets and potentially being used inappropriately later. But there are other potential clinical risks, not the least of which is the unconscious shading of our decisions by finances. The article reported me saying:

“Patients will have to be especially careful that the treated condition is improving and, if it is not, they need to check with their physician for a possible change in antibiotic therapy,” he said. “The pressure to prescribe just the least expensive medicines means we all — doctors and patients — have to be sure the treatment is proper and effective, otherwise we are at risk of being penny wise and pound foolish.”

Considering the economics of health care and insurance companies, I also find it interesting that I, as a physician, am "contracted" with an insurance company and must charge a copayment for an appointment, but a pharmacy can drop a charge and "eat" the costs as they drum up other business in their store.

Is that the face of "free market" medicine if we move in that direction? I worry that small-office private primary care doctors will be crushed by large medical groups that off-set costs in one area to build up volume in another if these marketplace behaviors expand throughout health care.

A supermarket can make more money by linking their business to health care -- getting more customers in the door for free antibiotics will likely lead to more money spent on groceries the same day. It is a good business model. But, is it a good health care model?

Will I someday have to open a bookstore/coffee shop in the front room of my office and then not charge my patients any copay to compete with larger offices? And, if I do, will it be enough to "compete" against the false value of "health care supermarkets?" Will my patients benefit?

Free antibiotics. A good thing? A clinical risk? A sign of things to come? Let's talk in ten years.

--Timothy Malia, MD