PHILADELPHIA REFLECTIONS
Musings of a Philadelphia Physician who has served the community for six decades

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The Pharmacy Example.

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Pharmacy

The Pharmacy Example. It would seem, a natural place to introduce computing to medical care delivery would be the drug store. Almost everyone is familiar with the process of the doctor writing out a prescription and giving it it the patient. And it's likewise familiar how a patient takes the prescription to the store, gets the bottle of pills, and pays for it. The drugstore seems to be a single link in the chain between doctor and patient, with only the prescription adding input, only the bottle of pills generated as output. So let's begin there, watching an example of how simple things rapidly become complicated. The pills are standard, the inventory is already digitized, insurance can be made to enforce a standard number of pills in a refill, the pharmacist can then be replaced by a high school girl. You give the patient 30 pills, and 30 days later he needs another 30, right? Well, not exactly.

The computers are in the drugstore all right; usually five or six of them. What's missing is the professional latitude of the former owner-pharmacist, replaced by an automated assembly line. Druggists as we knew them began to disappear around 1970, and computers probably had a lot to do with that first step of moving from corner drugstore toward pharmaceutical ATMs. Prior to World War II, most pharmacists could even compound capsules from powders, and mix various-colored liquids in a bottle. That is to emphasize, the corner drugstore and its friendly owner-operator were well on the way to disappearance, quite a while before outpatient prescribing was overwhelmed by health insurance. It must not be imagined that disentangling insurance from outpatient prescribing would automatically take us back to a system which allows more professional latitude between ancient professions. That might well be desirable, but opportunity is fading fast.

The drug stores by 1970 had already automated most of their process to a point where insurance designers could easily imagine substituting insurance billing for patient billing; and linking that combined payment system to a pill fulfillment system. If only a way could be found to substitute bottles of pills for twenty-dollar bills, the drugstore would already be on its way to becoming a cash-dispenser, or at the very least, a candy-dispensing machine. Technology had only been waiting for someone to pass a law.

Shortages. Very probably the concepts of centralized control began with the Pharmacopeia. Originally, this term referred to a list of drugs the store kept in stock; an inventory list. When supplies got low, they were re-ordered in an amount judged sufficient until the next delivery. Certain drugs and certain supply houses were preferred, so once a decision has been made, the stores and the suppliers kept themselves ready for business. Hospitals maintained a more elaborate Pharmacopeia, usually with a committee appointed to oversee the list. Until the Second World War, most of the patients were in the indigent wards, so custom evolved into the idea that private patients could have anything the doctor ordered, often ordered from the pharmacy across the street. The Pharmacopeia was for indigent patients, taking the view that the committee was to decide matters of quality, and the hospital pharmacist had the latitude to order the cheapest generic version available. This didn't always suit the doctors with private patients, so there was a tendency to extend it to all drugs, quickly jerked back into line by the private physician giving a prescription to the patient's family, to be filled in the drug store across the street from the hospital. When insurance came along, this sort of thing lost its point, so peace was restored by converting everybody's drugs to the more expensive variety, essentially disbanding the committee. It was an important turning-point: the conflict between quality and cost was almost instantly resolved by letting insurance just pay for the best. When the pharmaceutical companies saw what was happening, inclusion on the favored list began to revert to the quiet preferences arranged between the companies and the hospitals. In time, drug prices began to go up, insurance companies noticed, and the committees had to be restored in order to assure that quality was preserved. Around 2012, shortages of vital drugs began to appear; up to that point, shortages were unheard-of. But Philadelphia was somewhat quicker to recognize what was happening, because it had all happened in Philadelphia in 1778. Price inflation invariably provokes rationing, and rationing provokes shortages. And shortages soon lead to rioting, when it is discovered that shortages have appeared, in spite of hoarded abundance. American pharmaceutical firms found that generic drugs were unprofitable compared with drugs under patent, so they stopped making generics. Third-world countries continued to make generics, but only when it was profitable, and free of probing inspectors. Shortages are a likely sign of government intrusion; shortages in the midst of abundance are a certain sign of it.

Regimentation. Once hospital nursing systems got around to individually recording drug use, it was only a matter of time before someone got the idea of devising a set of "best practices", matching them with what had actually been prescribed, and identifying which doctors complied best with the best practices. That's where reality sets in.

The designers of pharmacy systems have assumed that directing the computer to record what ought to be done, is the same as describing what has actually been done. Unfortunately, in an outpatient environment the patient is generally acting as his own nurse, and is almost always somewhat sick. He is also paying at least a portion of his bill. When the cost of a cheap generic is a penny a pill, slack can be created in the system by throwing in a few extra pills. However, when an expensive brand name drug, say one costing ten dollars a tablet, is authorized by the insurance, great care is taken to dispense precisely 30 tablets every 30 days, regardless of Christmas or Sunday, Hell or high water. When a pill accidentally goes down the drain, or gets forgotten, or wasn't in the bottle to begin with, the situation is exaggerated that the patient is short of the expensive pill, but has a surplus of cheap ones. He tends to wait until they match up, but the computer clock is running and usually won't allow the slack to catch up with itself. At this point, often a relative -- let's say the daughter flew in from California -- discovers that the patient hasn't been taking pills which are fearfully expensive, and therefore vital to survival. It is very likely a fact that the expensive pill being skipped is indeed the one most likely to be critical to his condition. The dilemma almost always reaches crisis proportions at a time when there is no one available to over-ride the computer. The rest of this little scene is best left to the imagination.

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