Faculty Bibliography

The daily squeeze hit me hardest the morning I saw a likable 68- year-old patient of mine waving at me through my waiting-room window. I'd been treating him for years, but he didn't have an appointment and I barely recognized him with his newly bald head, yellowed skin and shaking hands. My office staff wanted to turn him away because the day's schedule was already packed, but I sensed his desperation and made time for him. In the examination room, he told me that his oncologist had informed him bluntly that his cancer had spread and then dismissed him. I was the man's internist, his gatekeeper to the medical world, and he had returned to me -- not for expertise, but for warmth. The pressures are fierce for doctors to compromise their professionalism, their humane instincts, for business reasons. The Medicare Payment Advisory Commission suggested last year that the United States needs a payment system that more accurately reflects doctors' rising costs. Most doctors would agree. While it is true that we still make a decent living, at the same time we must hire more and more staff members to handle certifications, pre- certifications and referrals while also accepting lower payments. And with the new fee reduction almost certain to filter down from Medicare to the HMOs the way such reductions have done in the past, it will become increasingly harder to stay level. Struggling with my professional identity, I try to find myself in the famed physicians' Hippocratic Oath, which says, in part, 'In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction. . . .' Well, doctors abandoned making house calls and gave up accepting a chicken in lieu of payment long ago in most parts of the industrialized world. But 'for the good of the patient' remains a noble ideal that has guided physicians for centuries. I feel it must continue to guide me

France, for one, has successfully negotiated prices that are as much as 15 percent lower than those suggested by manufacturers for the stomach medicine Prilosec (made by AstraZeneca), the cholesterol- lowering drug Lipitor (Pfizer) and the top-selling antidepressant Paxil (GlaxoSmithKline). In the United States, Lipitor, which brought Pfizer revenues of $8.6 billion last year worldwide, costs $2.38 per 10 mg tablet wholesale -- that is, the cost to pharmacies. The same pill is sold to French pharmacists for 75 cents. It costs 93 cents in Britain. The idea that Medicare would name the price it is willing to pay for something is not entirely foreign. Medicare already dictates doctors' fees and laboratory and hospital reimbursement. Under the current system, doctors have an option. We can be Medicare providers and accept that the prices the government decides are fair and reasonable, or we can go outside the system entirely and not accept Medicare at all. If we choose the latter, our elderly patients will not be reimbursed for our services. We can charge top dollar, but then many patients would not be able to come to us. We will survive outside the system if we provide an exclusive service that is in high demand. This 'loophole' is what makes the current system legal. Doctors and hospitals don't have to accept these scaled-down prices, and our patients don't have to go to places that participate. But if either side chooses to decline the system, the payment is made out- of-pocket. The same logic would apply to drug manufacturers. Extending this system to include the new prescription drug benefit would go a long way toward keeping drug prices down. Medicare could decide which drugs are duplicates and which have generic equivalents. If patients want a drug that is not covered by Medicare, they could pay for it. If a drug company brings to market a product it perceives to be exceptional and not simply a duplicate of what exists, then that company will have the option to go outside the system and charge full price. The overall effect will be the savings of billions of health care dollars

A longtime patient of mine who suffers from severe asthma came to my office two weeks ago gasping for air. I knew as soon as I put a stethoscope to her hissing chest that I was going to have to admit her to the hospital for several days of intravenous steroids. The doctor in the New York University emergency room suggested -- strangely, I thought -- that I give her oral steroids first. I told him I disagreed. In such a severe case, intravenous delivery was by far the most effective way of calming an inflamed set of spastic lungs. But when I went to see the patient later that day, I found she had received the oral version, and, what was worse, she was still wheezing badly. The nurse explained to me that there was a shortage of methylprednisolone, the IV steroid I had ordered, because of the war in Iraq. Clearly, I needed to find out the extent of the problem. I contacted Dennis Karagannis, associate director in charge of supplies for NYU Medical Center's pharmacy. He explained that many intravenous and emergency medications were already in short supply because the FDA had stepped up regulation of their manufacture two years ago to ensure purity and consistency. At the same time, the market had changed, further contributing to the shortage. Many of the same products had become generic, making them cheaper in any form. A 125 mg vial of the IV steroid, which had sold for $6 a vial 10 years ago, was now only $2 a vial. The increased pressure on this shrinking supply suddenly worsened several months ago as the military began stockpiling medications for the upcoming war, Karagannis said. 'The companies ship right to the government,' he explained. 'We have to wait for the next production load. Right now several supplies are on back order or allocation, where you only receive your current monthly usage.' It turns out that steroids, lidocaine (a pain medication), morphine, atropine (a nerve blocker), dextrose (a sugar solution), sodium bicarbonate and some injectable antibiotics are among the drugs now in short supply

When [John Elias] hears about the Medicare measure, with its high deductibles, co-pays and the possibility of $3,600 coming out of his pocket, he simply shakes his head. 'Got any samples?' he asks me. Elias uses a wheelchair. He has diabetes and hypertension, and because he has no drug coverage, he relies on free samples. When I run out of his medicine for blood pressure, it soars out of control. His blood sweetens and unsweetens depending on whether I can offer him his diabetes pills. Many of my elderly patients overcome the cash-for-pills hurdle by turning to New York's Elderly Pharmaceutical Insurance Coverage (EPIC) plan. The feds should have looked more closely at this plan. With EPIC, if a Medicare patient is able to show need and an insufficient income, there is only a small out-of-pocket annual fee for medications and a small co-pay. The rest is covered by the state. New York, in turn, is responsible for negotiating lower prices with the drug companies for its EPIC members

Influenza affects up to 20% of the U.S. population in a given year, with 114,000 people hospitalized on average. While roughly 70 million Americans receive the flu vaccine every year, another 70 million should get it but don't. Health care workers, older people, those with respiratory or chronic illnesses, pregnant women and anyone who may come in close contact with the flu all should be vaccinated. In fact, it may not be long before the vaccine is recommended for everyone. WHO also has done a good job of not spreading panic by connecting the flu to the media megaphone the way SARS was. During the past century, three influenza pandemics -- diseases spreading over a large region -- caused millions of deaths worldwide, social disruption and profound economic losses. The scourge of 1918 wiped out 33,000 people just in New York City. Luckily, no one is hyping this history. This year has been a bad flu season in Australia and Chile, which might be a harbinger for a bad flu season here. In addition, since we have just experienced two mild flu seasons, some experts say that a severe one is due. But such speculation is about as sure as predicting the stock market. We are better off preparing, not predicting

Accurate information and an informed perspective could bring the public's fear of smallpox more in line with its real risk. Exaggerating the side effects of a largely safe vaccine is not the best way to treat the fear of the virus

'The Piano Tuner' by Daniel Mason is reviewed.

Added to this mix we now have the tangible-seeming risk of SARS. My waiting room is filled with patients brimming with the same question. ''Could I have SARS?'' a patient blurts out. Unsolicited, an office secretary replies, ''You must ask the doctor.'' Meanwhile, the 13-inch television set in the middle of the room is playing all SARS all the time and updating my patients on the virus every hour. New Yorkers are a nervous bunch to begin with, and their doctors are no exception. Most of us, doctors and patients alike, are medical Zeligs; like Woody Allen's character, we take on the symptoms and even the personality of the latest threat. In this case the global health alert and travel advisories that are meant to contain the droplets of the virus also spread virulent fear by word of mouth. The city felt this fear and vulnerability for many months pre-SARS; now the fear of bioterrorism has been converted into a fear of a deadly mystery virus. My office phone is ringing continually with respiratory complaints. I know better than to counter these concerns with the bald statistic of zero deaths from SARS in the United States so far. I don't want to appear to be playing down serious potential risk. If SARS spreads as easily as the common cold but is more deadly, it could cause medical mayhem here. Because we live in close quarters, the spread of any disease may be eased by proximity

The idea that Medicare would name the price it is willing to pay for something is not entirely foreign. Medicare already dictates doctors' fees and laboratory and hospital reimbursement. Under the current system, doctors have an option. We can be Medicare providers and accept the prices the government decides are fair and reasonable, or we can go outside the system entirely and not accept Medicare at all. If we choose the latter, our elderly patients will not be reimbursed for our services. We can charge top dollar, but then many patients would not be able to come to us. Extending this system to include the new prescription drug benefit would go a long way toward keeping drug prices down. Medicare could decide which drugs are duplicates and which have generic equivalents. If patients want a drug that is not covered by Medicare, they could pay for it. If a drug company brings to market a product it perceives to be exceptional and not simply a duplicate of what exists, then that company will have the option to go outside the system and charge full price. The overall effect will be the savings of billions of health care dollars. Europe accounts for just over 20 percent of the pharmaceutical industry's more than $400 billion world market, according to IMS Health. The United States accounts for 46 percent. But with our unregulated practices, we're the source of more than 60 percent of the industry's profit. We're filling its coffers; we should use our influence to dictate prices. After all, the current $400 billion plan for Medicare prescription drug coverage can buy a lot more drugs at the prices Europeans pay for them

The major drug companies have tried to resist controls but have been largely ineffective in dictating European prices. From time to time, they threaten not to supply the drugs, but that never happens. Last year, several of the world's biggest drug companies, hearing that Germany's Health Ministry was planning to impose a 4 percent price cut on prescription drugs, collectively donated almost $200 million to Germany's state-sponsored health plan with the express goal of staving off the reduction. Germany took the subsidy yet went ahead with the price cut anyway, and because 80 percent of prescription drugs in that country are purchased by the public health insurance system, the drug companies had no choice but to accept it. The idea that Medicare would name the price it is willing to pay for something is not entirely foreign. Medicare already dictates doctors' fees and laboratory and hospital reimbursement. Under the current system, doctors have an option. We can be Medicare providers and accept that the prices the government decides are fair and reasonable, or we can go outside the system entirely and not accept Medicare at all. If we choose the latter, our elderly patients will not be reimbursed for our services. We can charge top dollar, but then many patients would not be able to come to us. Extending this system to include the new prescription drug benefit would go a long way toward keeping drug prices down. Medicare could decide which drugs are duplicates and which have generic equivalents. If patients want a drug that is not covered by Medicare, they could pay for it. If a drug company brings to market a product it perceives to be exceptional and not simply a duplicate of what exists, then that company will have the option to go outside the system and charge full price