SciQuest.org

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Finally, one of my pet peeves is being addressed by Amazon. They are introducing “Frustration Free packaging” in time for the holidays.

My cortisol levels start to surge when I receive a package with plastic form fitted around the object, metal twisty wires holding it together and plastic so tough my scissors can’t even cut through it. None of it is recyclable and usually the packaging is bigger than the product inside.

Amazon is now beginning to work with the manufactures to eliminate this waste and ridiculous trend that seems to have sprung up everywhere. So far they only have 19 products that feature recyclable boxes that are easy to open. Jeff Bezos, CEO of Amazon, says the initiative will take many years, but the vision is to offer their entire catalog of products in Frustration-Free packaging.

To view the selection that will avoid wrap rage, go here. We need more of this!

The answer is #3 Diffuse esophageal spasm.

Here is another radiograph that shows barium contrast material that highlights the esophagus in a spiral formation. The esophagus is made of smooth muscle and it contracts to propel food down to the stomach. Esophageal spasm is an abnormal uncoordinated contraction and it can cause mid chest pain and slow the progression of food after swallowing.

Signs and symptoms of esophageal spasms include:

• Pain in your chest, often intense, which you might mistake for heart pain (angina)
• Difficulty swallowing (dysphagia)
• The feeling that an object is stuck in your throat (globus)
• Bringing food back up (regurgitation)
• Heartburn, a burning sensation that may radiate from your upper abdomen to your neck, sometimes leaving a sour taste in your mouth

Good diagnostic work, readers.

Head on over to “Cranky Fitness” , a cool and fun website where “healthy living is a pain in the ass”. I am the guest blogger on eating a healthy breakfast. Check it out.

You be the doctor. This is a barium swallow and you are seeing the esophagus within the chest area with barium highlighting it. What is the diagnosis?

#1 Ingested foreign body
#2 Esophageal diverticula
#3 Diffuse esophageal spasm
#4 Gastric linitis plastica
#5 Esophageal carcinoma

Click on the image for a better view and the answer will be posted tomorrow.

I was interviewed for a widely read publication in the Pharmacy world called Drug Benefit News. They kindly gave me permission to reprint it on my blog:

Volume 9, Number 21 October 31, 2008

The following interview is part of an occasional DBN series that examines hot-button pharmacy benefit issues though the words of the industry’s thought leaders. To suggest a topic and com- mentator, contact Neal Learner at nlearner@aispub.com. Toni Brayer, M.D., has practiced internal medicine in San Francisco for more 20 years, and is regional chief medical officer of a large hospital/physician network in California. She is a fellow in the American College of Physicians and has served as president of the San Francisco Medical Society and chief of staff at California Pacific Medical Center. Brayer is a well-known speaker and author of the popular blog EverythingHealth (www. everythinghealth.net). DBN caught up with Brayer to get her view of how well the pharmacy benefit works in the doctor’s office.

DBN: How would you assess the state of the pharmacy benefits industry from a physician’s perspective?

Brayer: The pharmacy benefit industry is confusing and overwhelming to physicians. There is a lack of understanding about how they operate and the difference between mail-order pharmacies and PBMs. Some are subsidiaries of health plans, some used to be owned by big pharma. There are perceived conflicts of interest. It is unclear if PBMs bring any value to health care, and if they do…who benefits? Pharmacy costs continue to increase by double digits, and PBMs are thought to be part of the problem, not the solution.

DBN: Do you see significant differences in the way that individual health plans and/or PBMs provide Rx drug coverage?

Brayer: Physicians deal with too many health plans and numerous PBMs, and from our view they have no consistency. We have no way of knowing the various protocols and regulations they operate with, and new product designs make it impossible to keep up. Formularies are cumbersome and change all the time, and it is unclear who controls the formulary. It appears that formularies are based on [achieving] optimal revenue, not evidence- based. The goal should be to reduce hassles for primary care physicians and lower costs to patients and purchasers of health care. Health plans and PBMs are seen as the problem, not the solution.

DBN: What are the biggest hassles that you face every day in getting patients the drugs that they need?

Brayer: Prior authorizations (PA) are exploding and require both staff and physician time to muddle through. A drug that is covered on one plan might need a PA on another. The protocols are different for each one, and some require the physician to list every drug the patient has previously tried and failed (with dates), which means an extensive chart review. It is unclear what is considered a generic, a brand or a preferred drug with each plan or PBM, and there is no transparency in pricing. Pharmacies do not automatically refill ongoing prescriptions and call or fax the doctor’s office for refills, even when it was clearly written on the Rx. Requiring tamper-proof prescriptions is a huge hassle, and it is unclear that they reduce drug abuse, but they certainly reduce physician efficiency. Pharmacies in 2008 are akin to the DMV [i.e., department of motor vehicles]. It is a nightmare to get a prescription filled. The cost of pharmaceuticals is obscene, and the waste we see within the pharmaceutical industry (which drives up cost) is infuriating.

DBN: To what extent do you consider the cost of a drug when writing a prescription?

Brayer: Always. But information is not clear, and I advise patients to use mail order or Costco or price shop. The variation in pricing is not rational, and the fact that patients can only get one month at a time for chronic medications is just plain gouging them for the dispensing fee and monthly copayments. Certain generic drugs should cost pennies a pill, but even generics have inflated pricing if the patient pays out of pocket. It is unusual for any medication to cost under $40, even if it is a generic that has been around for decades. That is a marketplace out of control.

DBN: What would you suggest to PBMs, health plans and others to improve the system?

Brayer: Initiate education for physicians and transparency for everyone. Who benefits from PBMs? Can you really be transparent about rebates, kickbacks and back-room deals? Make formularies evidence- based, and stop the onerous PA. Price non-generic drugs lower if there is no generic to offer as an alternative (example: transdermals, bisphosphenates, certain inhalers, certain antibiotics, once-daily dosing regimens).

DBN: What can or should physicians do to improve the operation of the pharmacy benefit?

Brayer: Physicians are at the bottom of the food chain and do not have the ability to improve this operation. As I see it, PBM customers are the health plans and the pharmaceutical industry. Health plan customers are the employers or purchasers. Employer customers are the stockholders or company owners. Physician customers are the patient. Physicians and patients are out of the loop except as the user of the services. Since we are no one’s customer, in a free market we are irrelevant.

Dr. Karen Kim, director of Pooler Pediatric Clinic, in Pooler Georgia, wrote the above first letter (click on it for a better read) to her staff and colleagues.

After the backlash, she wrote a 2nd letter, which further inflamed the situation. A few days later a resignation letter said she would be leaving Pooler to devote more time to caring for her 7 children at home.

This is a good case study in how NOT to be a medical director (or any other manager of people).

• Don’t bring politics to the workplace
• Don’t call the President Elect “Evil Incarnate” in writing
• Don’t threaten your staff and colleagues
• Don’t insult your staff by calling them names like “lazy” or “slacker.”
• Don’t act like a victim
• Don’t be a total jerk

Great advice I received at an early age from my mother was, “Don’t ever put in writing anything you wouldn’t want to be seen by everyone.”

Now, with the internet it means it will be seen world wide. Sorry Dr. Kim. You never met my mom.

Huntington, West Virginia has been named by the Centers for Disease Control (CDC) as the unhealthiest city in America. Nearly half of the adults in the five-county metropolitan area are obese and Huntington leads in heart disease, diabetes and elderly people who have lost their teeth. Contrast that with Burlington, Vermont, the nations healthiest city. What’s the difference? It all boils down to money and education.

First let’s look at Huntington. Its poverty rate is worse than the national average. It is a blue-collar white skinned community – people of English, Irish and German ancestry. Over the last few decades the manufacturing jobs have left the area and the remaining jobs are low paying. The largest employers are the hospitals and Marshall University.

Contrast that with Burlington. Only 8% live at the federal poverty level, compared to 19% in Huntington. Nearly 40% of residents have a college degree, compared with 15% in Huntington.

In Burlington, healthy eating is popular. Vegan options are plentiful and even low-income residents have the choice of bulk rice and grains and vegetables at local markets. In Huntington, donut shops abound and Pizza, KFC and fast food offer the best bargains to poor residents.

In Burlington people ride bikes, hike, ski and garden. Huntington has few parks and even on sunny days, residents are not out and about. The rural roads are busy and there are few sidewalks.

Huntington allows smoking in restaurants and local bars and even the hospitals have not been effective in forbidding smoking. Huntington’s culture is one of “you’re not going to tell me what I can or cannot eat” and the fact that poor eating, lack of exercise and smoking causes medical problems does not seem spur change.

Huntington officials are striking back and saying that the CDC report doesn’t exactly “mention” their area by name but includes a larger square mile area, of which they are just a portion. Despite the excuses by the city officials, a local physician, Dr. John Walden who is chair of family and community health at Marshall University says,
“I don’t know that I’ve ever been in a place where I’ve seen so many overweight people.”

In case you missed this…Colbert Nails it. Watch to the end for his take on the Statin (Jupiter) Trials.