Sunday, July 13, 2014

The U.S. healthcare system, up my nostrils

If you'll bear with a brief personal medical narrative, I think it holds some lessons about overutlization and economic incentives in our healthcare system, though I'm not entirely sure what they are yet.

I've been plagued with nasal allergies all my life, and almost twenty years ago I also developed nasal polyps. The worst of the allergy symptoms moderated at about the same time, except when the polyps flared up, which would happen when I had a cold. On three separate occasions, I took steps to have the polyps removed surgically, which entailed taking the steroid spray Nasonex for a few weeks and the scheduling an operation. On each occasion I backed out of the operation. On each occasion, too, the Nasonex vastly improved my breathing, but I always went off it because I was under the impression it's bad to inhale a steroid indefinitely.

The last time I put this process in motion, in February 2012, I got some straight talk from the ENT doctor. Polyps and allergies require constant maintenance, he said. If I got the polyps removed, I'd have to stay on the steroid, and the polyps would likely grow back and have to be removed again. He convinced me that using Nasonex indefinitely would not be dangerous.

"Every time I go on Nasonex the polyps disappear," I said. "If I need to stay on the drug after I get the operation, what do I need the operation for?" He allowed that I had a point at wrote me a prescription refillable for a year.

I remain on Nasonex and have had zero trouble breathing through my nose and zero polyps for 18 months.  Insurance issues opened a new chapter in the saga, however, and prompted new behavioral changes -- one working as planned for the insurer, and one perhaps not so much.

This year, our insurer, my wife's employer, a hospital group, introduced a $100 deductible for drugs, along with preferred pricing if we get the drugs at a member hospital pharmacy. My original prescription called for two shots of Nasonex per nostril twice a day; by this end of this year, I had already vastly reduced that, and a prescription written this year, by my primary care physician, would have effectively doubled the cost by giving me half as much per copay.  So I have taken three steps.

First, I asked her to double the dosage, so I get twice as much per copay. Then I had my wife pick up the drug at her workplace pharmacy, which is a pity for our local pharmacist. Next, I further reduced my use to one shot per nostril every other day  -- one eighth of the original dose, with zero negative effects. I am not going down to zero, as I've been down that road before, and the polyps and congestion always return.

While contemplating this blog post, a potential step 4 occurred to me. I am still on my first Nasonex bottle, obtained in February.  Each refill is two bottles, and I get I think two per year. Though I still have an unused bottle, it would make economic sense to refill now, and then refill again before year's end.  Then the supply would take me through next year, and I'd get to skip the deductible.

The insurer has succeeded in reducing my usage, which is good for me and good for the insurer. The insurer has also encouraged me to hoard, however, and could therefore lose next year's deductible (unless I need other prescriptions).  The insurer might do better by giving me a straight incentive to use less on a permanent basis -- though that might also entail crimping the doctor's freedom to prescribe as much as she sees fit, or as I ask for.

I must say, thinking about this has led me to wonder how many of the people you read about in healthcare hardship tales who cut their dosage for financial reasons are better off at the lower dosage. That's a terrible way to limit usage. But there's probably a vast amount of over-prescription.

As for the two prior ENTs who had encouraged surgery, I have to wonder whether they'd thought that course through, and whether the economic incentive not to think it through has an effect on their practice.

And finally, in a chapter yet to unfold, the duration of Merck's patent protection on Nasonex is disputed. In one sense it runs out this very much. Teva has filed an application to produce generic Nasonex, and Merck has sued to block it.

My doctor mentioned that there are over-the-counter steroid sprays. For the moment, I'm not prepared to change a winning game. And the alternative might not even be cheaper -- until I next hit the deductible. I'd jump to generic Nasonex in heartbeat, though, once it's available.

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