The PT Barnum Factor in American Healthcare: One Prescription at a Time

WASHINGTON, DC - No matter who first uttered the phrase most oft attributed to showman PT Barnum - "There's a sucker born every minute" - the U.S. healthcare system has embraced and expanded on that sentiment many times over. Patients can and do chronicle stories that tug endlessly at our humanitarian side, reformers cry for lowered costs and personal responsibility, and fans of market-based profits hold tight to expanding a system drunk on its own complexity and over-consumption by a few.

So, who's the sucker born every minute in this healthcare and wealthcare mess? You and me. The patients. The family members. The concerned and committed citizens. The insured and the uninsured. The taxpayers. All of us.

I have watched many atrocities and many miracles unfold over the course of my husband's treatment for chronic artery disease during the past 20 years. I completely agree with the assessment I once heard Sen. Tom Daschle (soon to be this nation's top health policy czar and Secretary of Health and Human Services) make when he described the U.S. healthcare system as displaying "islands of excellence in a sea of mediocrity." My husband has been blessed with some of the finest care this nation has to offer. Yet he has had to struggle with dishonesty, indifference and, in my opinion, outright fraud as he has attempted to be that personally involved consumer we seem to be charging with some sort of ability to alter the forces raking massive profits out of this system without regard for patient health or national well-being.

Sen. Daschle often says that the healthcare system is complex in this nation and that reforming it will require knowledge of that complexity and efforts to mitigate negative outcomes of reform as we create better conditions for more people. I agree. But we have to start from a position of honesty and doing so requires that we tear apart the processes patients encounter every day and look at the costs and conditions driving costs higher and damaging lives.

I recently observed the process associated with just one of my husband's eight prescription medications and became troubled thinking about millions and millions of these transactions and the impact on the system.

My husband's cardiologist prescribed for him a drug called Niaspan, produced by pharmaceutical giant Abbott Labs. The drug offers an "extended release" high dose of niacin, also known as vitamin B3, and apparently is indicated for patients for whom traditional dietary modifications and cholesterol lowering drug therapy have not been sufficient to create the optimal artery protecting results. My husband trusts his cardiologist, and he filled the prescription. He was annoyed by the out-of-pocket costs on top of the Medicare premium he pays as well as the Medicare Advantage plan and supplemental coverage premium he pays to a private insurance company in order to keep his out-of-pocket costs down.

Within a short time, he experienced terrible flushing and itching after taking his Niaspan - some of the side effects of the drug which have been noted by many patients. He mentioned the side effects to the doctor and pharmacist who suggested he take an aspirin prior to taking the Niaspan to relieve the flushing a bit. He tried that. Sometimes it helped and sometimes it did not. So the next time he saw his doctor, he mentioned that he hates taking the Niaspan because of the cost and the flushing. The doctor then suggested he cut the tablets in half and wrote a new prescription.

Lo and behold, my husband used up the supply he had and then went to fill the new prescription, but then found out the first part of this troubling saga of just one drug prescribed to one patient. While he expected his out-of-pocket cost for Niaspan to also drop, it did not. Apparently, a one month supply costs approximately the same amount to him whether that one month supply is 15 pills or 30 pills or 45 pills. When my husband challenged the pharmacist, he was told he should take it up with his doctor and that the doctor could write the prescription for 30 pills.

The implication was that then my husband could fill the 30-pill, 30-day written prescription, but follow the verbal dosing orders from his doctor and cut the pills in half and then only refill the 30-pill prescription every couple of months. Wow. And this was the advice from pharmacists at a major pharmacy that fills millions of private insurance and government program prescriptions every month. Imagine the charging and cost implications if millions of patients and programs pay the same for 15 pills as for 30 or 45 and so on. No per unit pricing here. You may pay $2 a pill for Niaspan or you may pay $1.50 or even $1 a pill - and those cost differences are paid by insurance programs and government programs too.

Well, this isn't the end of the Niaspan story for my husband. I went to one of those community discussions called for by Sen. Daschle and the in-coming Obama administration during the past couple of weeks. We started talking about the issues we see and want fixed. I relayed the story about the Niaspan and the costs. Two of the people at the meeting were doctors and three were nurses. One piped up, "Why does he take that? Couldn't he just take over-the-counter niacin?"

I said I didn't think the drugs were the same. The healthcare professional laughed. She told me that one of the things she routinely see is patients prescribed costly "extended release" or otherwise formulated prescription medications that could fairly effectively be replaced by far cheaper over-the-counter versions of the same drug. The other health professionals nodded, some laughed. I did not laugh.

The joke's on us. I am dumbfounded. Not only did my husband's doctors not talk with him honestly about the relative effectiveness of Niaspan in comparison to vitamin B3 supplements, his pharmacist and pharmacy participated in a billing shell game that left him in the dark. And I am 100 percent sure by the reaction I saw at that healthcare community discussion that this happens a tremendous number of times within our system.

My husband is not stupid, and he tries to take personal responsibility for choosing cost-effective and appropriate treatment. He does not wish to end up needing more invasive and expensive care. And I try to help him negotiate the costs and care as best I can. We do often trust his medical professionals - from the doctors right down the line to the pharmacists - to be honest and forthright about treatment options. Clearly, we cannot trust that - and clearly, trying to force patients to be more personally responsible for their care is not going to address the rampant greed embedded in this system top to bottom. Think of every procedure and prescription in this light and oh my, think about costs.

A huge part of the cost escalation in our healthcare system is not caused by patients demanding more expensive care - and the complexity of this profit-based healthcare model with market forces bursting forward in all sorts of unregulated ways to scrape profit from every corner of the process cannot be fixed by glibly asking patients to take more personal responsibility. Try questioning a cardiologist one too many times and you'll be looking for a new cardiologist - patients know that. There are honest physicians in the system to be sure, but it can be daunting for patients to find a way to identify those people - especially in the face of serious illness.

We've got a system propped up by illusions of grandeur sprinkled with isolated illustrations of excellence. Some people get great care, some lives are saved that would not have been in the recent past, and some people feel comfortable with their healthcare situations. But we've also got a system that's a messy mix of profit-taking and misinformation that makes it nearly impossible for the vast majority of patients to truly advocate for themselves in any way that could be relied upon as a cost containment strategy. And the profit-taking and dishonesty is bursting the public programs like Medicare that otherwise provide the best model for reform - and that's also a truth we're often not told.

We've become the suckers born every minute in the circus tent of U.S. healthcare. And it's costing patients and the nation billions and billions of dollars - and an awful lot of lives. For that we are all responsible.