But Think of the CHILDREN!

You ought to recognize that line as a classic refrain of those in a state of "moral panic."

According to a recently released study, 3% of all children and adolescents in the United States go without health insurance at some point in a given year:

That translates into almost 3 million U.S. children with no medical care at all and no access to prescription drugs over a full year. Slightly more than half of that number qualify for public coverage but aren't enrolled.

Overall, more than 9 million U.S. children are uninsured; some 18 million have a coverage gap at one time or another, according to the study.

But, surprisingly, this includes kids whose parents have coverage:

The authors of the first study looked at data from 2002 to 2005 on children and adolescents under the age of 19 living with at least one parent. The study included more than 39,000 participants.

Their analysis found that 3.3 percent of children and adolescents were uninsured, even though they had at least one insured parent. (emphasis mine)

What about demographic information?

Uninsured children and adolescents were 58 percent more likely to be Hispanic than white non-Hispanic; had double the odds of being from a low-income versus a high-income family; were 48 percent more likely to be from a middle-income rather than high-income family; and twice as likely to come from a single-parent home than a home with two married parents.

...children whose parents had less than a high school education were 44 percent more likely to be uninsured; they were also 64 percent less likely to be insured if their parents had public coverage rather than being privately insured.

None of this should be a surprise. Poor kids don't have adequate health care coverage. Middle-class kids are less likely to be insured than kids from richer families; kids whose parents make between $38k and $72k a year are just as likely to be uninsured as their poorer counterparts. Kids with parents who have limited education are less likely to be insured, probably because the parents are less likely to have jobs that offer comprehensive family healthcare plans.

Why haven't we passed legislature to provide all children with health care coverage? Remember, the people who typically vote against candidates daring to propose universal health care are also the people who are most opposed to family planning.

"But N.B.," say some members of the audience, "the article says that over half the kids involved qualify for public assistance but aren't signed up. That's the fault of parents, not the government."

You're right. But not providing health care for children is sheer negligence, and we punish people for child neglect already. The definition of child neglect is "any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation." It is considered neglect to fail to provide for a child's basic needs, and medical care is included among them.

About half of U.S. children without health insurance had to go without medical care or prescription medications while they were uninsured, said researchers from the University of Rochester Medical Center. Even more children went without preventive care, including receiving necessary vaccinations.

If you don't see why this is a problem, you're part of it. And if you don't see why there need to be laws mandating health coverage for children (and adequate government assistance for those who need it), you're still part of the problem. Until there are laws mandating health care coverage for all children, we're losing a battle. There are kids out there who don't get treatment for the most basic illnesses because they lack health care coverage. Maybe one of them is yours.

"Children are like flowers," they say. "You can never have too many."

If you aren't watering your garden and your flowers are dying, maybe you should rethink that assertion.

So...please! Think of the children!

Five "Myths" about Socialized Health Care

A friend of mine and I were having a discussion about "socialized medicine" the other night. After a lot of verbal parrying and thrusting we concluded at about 3:30 AM. When I woke up, I found that he had left me a message--a link to an article called "five myths about socialized health care." Here's the article. It's written by a "John Goodman."

Here's what I think about each of Goodman's "myths" and his ultimate conclusion.

Myth: "Socialized medicine gives you a right to health care."

Goodman argues that socialized medicine does not REALLY give you a right to care. In Canada, he claims, you don't have a right to heart surgery. You don't even have a right to a place in line.

In a sense, Goodman is correct. Just because the government provides single-payor insurance doese not mean that all people have the right to care automatically. That's why single-payor insurance/health care coverage is necessary but not sufficient. We need both single-payor health care AND a government declaration or law stating that citizens have a right to health care.

This argument is fallacious because it has inverted cause and effect. People aren't saying they want socialized medicine because it gives them a right to care. People are simply asserting that they have a right to care. People don't have a right to care under the current "free market" system, either.

Goodman claims that the market provides a means for people who need care more to get it--by paying more for it. He asserts that patients "waiting for care" in socialized systems are suffering. This is completely ridiculous. Hospitals in single-payor systems rank patients based on priority. The patients who are in most urgent need of care get it first. Care costs money; what Goodman is saying is that someone who really, really needs to get to "the front of the line" will magically produce as much money as it takes to get there. Where does this model account for people who really, really need to get to the front of the line but have no money for care?

Furthermore, many people are already sitting around and suffering because they can't afford medical care. Right now we are rationing care based on people's ability to pay rather than the severity of their illness. From a medical perspective, this makes absolutely no sense. You should treat the sickest patients first, not the wealthiest patients.

Myth: "Socialized medicine gives people higher-quality care."

Goodman claims that patients in Canada and the UK get worse care based on the number of patients in chronic renal failure who get dialysis or the number of patients who get coronary artery bypass surgeries. He also asserts that British doctors spend less time with their patients than American doctors.

In one study done in America (Ohio to be precise) physicians spent an average of 17.5 minutes with each patient. And it's true that physicians in Britain spent, on average, just under 10 minutes. But Goodman is exaggerating when he says that the physician barely has time to take the patient's temperature. Routine examination tasks like checking temperature and blood pressure are now relegated to nurses; doctors almost never do these things themselves.

If a patient is complaining of "coughing up yellow gunk" and "sinus congestion" and similar symptoms it generally takes about five minutes for the physician to listen to the patient's lungs and diagnose the problem appropriately because he's seen the same presentation of symptoms ten thousand times. The mean visitation time is likely skewed downward by the fact that some illnesses honestly don't take that much time to diagnose. Medical professionals report a prevalence of 62 million cases per year for the common cold; you can't really expect them to spend 20 minutes explaining proper treatment for that sort of thing.

Dialysis and coronary bypasses are strange endpoints. Dialysis is only actually medically necessary when kidney function declines to about 10%. 485,000 patients in America are estimated to have end-stage kidney disease requring dialysis or transplant; in 2005, 341,000 patients recieved dialysis, or 70% of patients with ESRD. 17,429 kidney transplants were performed, so 3.5% of patients recieved a new kidney instead (which is better).

In 2005 there were 32,375 Canadians requiring renal replacement therapy. Of these, 19,721 recieved dialysis, or 61%. It's true; this number is lower. But 12,654 patients recieved a functioning kidney transplant. So 33% of Canadians who needed a new kidney got one. That's TEN TIMES more people who recieved a new kidney, which is infinitely better than dialysis as far as patient quality of life and outcomes.

Also, we shouldn't brag about how many coronary artery bypass surgeries we're doing. The fact that people need bypasses means that preventative measures have failed. Ideally we'd do fewer bypasses because fewer people would need them because we provided better preventative care.

Myth: "Socialized medicine gives people more per dollar in terms of care."

Goodman claims that Americans don't get more care despite spending more money. He asserts that life expectancy is the primary measure used to judge "health care quality."

The WHO created a scale to assess health care quality in different countries based on five criteria:

-Overall level of population health
-Health inequalities (or disparities) within the population
-Overall level of health system responsiveness (a combination of patient satisfaction and how well the system acts)
-Distribution of responsiveness within the population (how well people of varying economic status find that they are served by the health system)
-Distribution of the health system's financial burden within the population (who pays the costs)

So no, no one is claiming that life expectancy is the primary criterion for evaluating health care quality.

Goodman also claims that more people who get breast cancer or prostate cancer in the US survive than those who develop these conditions in other countries.

See page 4 of this document.

It is true that the US outranks Canada and England in terms of breast cancer survival rates (in fact, it is 14% higher). But the survival rates for colorectal cancer are better in the UK and Canada. Childhood leukemia survival rates are better in Canada than the US. So are kidney transplant rates, as I already pointed out. So are liver transplant rates (about 20% higher, in fact).

Cherry-picking breast and prostate cancer is dishonest. Disease survival rates, incidences, and other statistics vary from country to country. Choosing two examples where the US outperforms other countries does not prove anything in the grand scheme of things.

Myth: "Socialized medicine gives people equal access to health care."

Goodman claims that care in countries with socialized medical programs does not really offer equal access because minorities still get less care. That's a terrible thing, but it doesn't really help his point. It isn't damning that socialized medicine isn't perfect.

Goodman then cites a survey of the elderly. According to the results, the elderly think that it is easier to get care in America, that they have shorter wait times, and that services are better.

This survey doesn't prove jack the way he's citing it. It's terribly misleading because as the author is presenting it he's basically saying "more elderly people think health care is good in America, so it is!"

I found the actual study cited--"The Elderly's Experiences with Health care in Five Nations" by Cathy Schoen et al., published May 2000. Let's see what it says.

12% of polled US elderly said it was "very difficult" to get care. 15% said the same in the UK; not a huge difference, and potentially attributable to randomness. 13% of Canadians said it was very difficult to get care--again, not terribly significant. Only 6% of Australians and 9% of New Zealanders thought it was very difficult to get care.

7% of those polled in the US said they had to wait five weeks or more for nonemergency surgery compared to 51% in the UK. So? That's the point--it's "nonemergency surgery." There's less rush to get it done. Having to wait to get an appointment to remove a mole or get a vasectomy is not a serious problem.

32% of those polled in the US rated their health care as "excellent." It is true that only 25% of those in the UK did the same, but New Zealanders had the highest rate at 39%. And again, 40% of US respondants reported "excellent care from their doctors," whereas 51% of New Zealanders did.

27% of respondants in the US described their most recent hospital stay as "excellent" compared to 39% in New Zealand.

9% of US respondants complained that their hospital stay was "too short." What in the world is this about? I think a team of medical professionals is in a better position to judge when you're well enough to go home than you are, especially since the longer you have to stay in the hospital the more it costs (both you and them).

I'm not going to go into the part of the study about prescription drugs because this study was released before Medicare Part D, and I'm sure that things have changed significantly.

As far as "younger patients preferentially getting care," which makes more sense--a liver transplant for a 30-year-old or a liver transplant for an 80-year-old? Who will ultimately benefit more?

In short, the US is somewhere in the middle of the pack. We do better than the UK and Canada on some issues but are vastly outperformed in most categories by New Zealand and Australia (and they have socialized medicine there, too). All this means is that if we institute universal health coverage we should learn from the flaws of the UK and Canadian system and emulate the good parts of systems from countries like New Zealand.

Myth: "National health insurance is an efficient way to deliver care."

Goodman says that the US health system is more efficient than other systems. He first asserts that this is true because the US has shorter hospital stays than anyone else. But he just cited a study where respondants complained that their hospital stays were "too short!"

What he says is true, to a point:

A 2006 survey says that in England the average length of stay was 6.3 days whereas in America it was 4.8 days (average of all diagnoses). One day's difference, really. That's not terribly significant in the long run. And hospital length of stay is not really an appropriate sole measure of the efficiency of health care systems.

Goodman continually uses the UK as an example of a poorly-run socialized health care system. What he fails to take into account is that the UK is not the only country with socialized medicine, and it does not have the best system by any stretch of the imagination. Saying that Britain's health care system is socialized but not as good as ours in terms of efficiency does not prove socialized health care is bad, it proves that Britain's health care system is less efficient. We would have to compare America to more than one country. Furthermore, if the British model is bad, we can choose to do things differently than they do, taking examples from what works in other countries and throwing out whatever doesn't.

Goodman also asserts that when you incorporate the cost to hospitals and doctors that Medicare and Medicaid are inefficient, but he doesn't provide numbers to back his assertion.

Cato: "Capitalism will fix the problem."

No it won't.

The free market won't fix health care because as far as the "free market" is concerned there is no problem. People who can't pay for goods and services in a free market economy don't get them. Ability to pay is the primary rationing mechanism. This means that it's okay if people don't get medical care if they can't pay for it because you only deserve things you can pay for.

What medical insurance does is not provide you with health care--it protects you against the astronomical cost of health care. Insurance works by spreading out the risk of illness over many people. This is why it's cheaper to insure a whole company, where the risk is distributed over a larger group, than it is to buy private insurance. Health care is not going to get cheaper. As we develop more advanced technology it requires more specialized knowledge to be a doctor or nurse. This means doctors and nurses require more expertise and education. This translates into increased costs.

To quote someone else's words on the subject:

For most Americans, providing health care ought to be different from selling soap; they won't tolerate doctors acting like commissioned salesmen and investment bankers. And if that means having less market competition and more regulation in the health care system, it seems to be a trade-off they're willing to make.

The free market is fantastic for regulating the price of most goods. Grecian urns? They're worth whatever someone is willing to pay. Luxury cars? Caviar? Designer clothing? Pepsi versus Coke? Price is a good rationing factor for all of these things. If people won't buy Pepsi because it costs more than Coke, Pepsi can lower their prices and see if people change their minds.

If you have a heart attack you don't have time to comparison shop. There is no incentive for hospitals to charge less. If you need a drug and there are no other drugs on the market that are just as good because the only drug that treats your illness is too expensive for you to afford, why should drug companies lower their prices to accomodate you? Medicine isn't a luxury, it's a basic human need. It cannot be subjected to the whims of the market. It cannot be treated like "just another service." There is no other industry where "buy" or "don't buy" is literally a decision between life or death.

Seriously. Every choice you make regarding health care directly impacts your chance of survival. We as a society, if we value the lives of our members, cannot afford to permit people to make the wrong choices. This doesn't mean people should be treated against their will. It means that people who want care should be provided with the best care available.

Patients often have no idea how to choose which care is best--that's why they go to doctors. If you develop an infection, do you know which antibiotic to use to treat it? In a true "free market" scenario drug companies would advertise their antibiotics directly to consumers and let them choose which one to use. This would be an absolute disaster; patients would wind up choosing antibiotics based on who connected with them through advertising rather than which antibiotic would actually treat the infection. If you have trouble believing this, consider the fact that 75% of consumers purchase brand-name drugs when buying over-the-counter medications despite the fact that on average generics cost about 2/3 as much and are equivalent products. They choose the more expensive product even though it is no better than the cheaper product. They do this because of brand recognition, faith in companies that produce brand name drugs, misconceptions about generic drugs, and many other reasons.

I have a hard time with the idea that patients who won't buy generic acetaminophen because they like Tylenol better will choose the right therapy for complicated illnesses. Which insulin should a diabetic use? Which ACE inhibitors have the best data to prevent strokes and heart attacks? What chemotherapy regimen is best? Giving patients full control over these choices is a mistake because they typically do not have the information necessary to make them--and most people overestimate their ability to make the right choice. If I had a dollar for every time a patient told me they should be able to get antibiotics whenever they wanted (and pick the ones they should get) because "I know when I'm sick" I would be a millionaire.

And that's what I think.

One More Thing to Write your Congressman About

PalMD has pointed out yet another area of healthcare that is clearly lacking and potentially in need of intervention.

In order to know how much short-acting insulin to take, a diabetic has to insert a test strip into their glucometer, prick their finger with a small needle, and touch the drop of blood to the test strip. This is usually done (at least) on waking, before every meal, and at bedtime---at least four times per day. Thankfully, blood glucose monitors are quite inexpensive and last a long time. Test strips, however, are expensive and disposable. How expensive? Depending on the brand of meter being used, and how many times you need to test, $30-$200 per month. These strips are usually not covered by insurance.

To give a comparison, good medical treatment for coronary heart disease, which usually requires about four medications, costs around $16/month. Older forms of insulin are also rather inexpensive (but the newer ones are costly). Without insulin, diabetics die---fast. Without test strips, diabetics don't know how much insulin to use.

He's absolutely right--and this is an absurd situation. Why don't insurance companies generally pay for something that is at least as necessary as insulin itself?

So...do something about it! Write, using this link. Or perhaps this one. Do both. The first is for the House and the second the Senate.

Don't know what to say? Try starting with what Pal suggested:

Diabetes is a serious disease affecting more than 20 million Americans. Part of the treatment of diabetes is the regular testing of blood glucose levels. In order to do this, diabetics must purchase glucometer test strips, which cost around a dollar a piece, and are usually not covered by insurance. For diabetics, especially those who have financial difficulties, the cost of test strips, which can be up to hundreds of dollars per month, makes diabetic treatment impossible.

I respectfully request that you look into potential solutions for this very serious problem, and bring this to the attention of your colleagues.

Sincerely...

Retail Pharmacy: Bringing Home the Bacon

I'm afraid that I must both simultaneously agree and disagree with a recent post by The Angry Pharmacist about an issue that hits fairly close to home.

Pharmacy professors wield the term "patient care" to their students like its what brings home the bacon every pay-period. Hate to break it to you kiddies, but they are full of shit.

You know what makes the store money? Filling prescriptions. Like it or leave it, filling an Rx fills your paycheck. This precious 'patient care' where you go out front and waste your time consult Mrs Smith on how to take her atenolol for the 4th time this month ends up costing the store money in the long run because you are not filling prescriptions. Spending hours with patients may make you feel warm and fuzzy, but getting off your ass and filling Rx's is what keeps your paychecks from bouncing.

As one of those ignorant pharmacy students, I'm sure my opinion is worthless, but I think that this sort of thinking is both immensely practical and startlingly backwards.

When I settled on pharmacy as a career I was 16. No one in my family was a pharmacist. No one in my family was a healthcare professional of any sort, for that matter. What initially appealed to me was medicinal chemistry. I wanted to research the next generation of drugs, develop treatments or cures for man's most devastating illnesses, and spend most of my life in a lab surrounded by bubbling beakers.

Once I actually got into heavy lab science (analytical chemistry) I decided I hated it. I made some phone calls and arranged for a summer job at a pharmacy in my hometown. After about three weeks of working there I was solid enough on all the mundanities of the job (register duty, cleaning and organization, data entry, etc.) that I was able to start dedicating my "brain time" at work to learning about drugs.

I started learning drugs in the most disorganized fashion possible, which is probably good because my mind wraps itself around trivia and traps it forever. I asked questions of the pharmacists on duty. I pulled package inserts off bottles while I worked and read eagerly. I was lucky to have preceptors that were willing to take the time to answer my inquiries and who encouraged me to continue trying to soak up as much knowledge as I could. The "big secret" that helped everything fall into place was the pharmacist who told me that drugs in the same class have similar names (like all ACE inhibitors ending in "-pril"). Suddenly I realized that I could generalize my knowledge about some specific drugs.

What was the point of that long story?

I started out thinking I wanted absolutely nothing to do with patients because I hated dealing with people and loved chemistry. Loving chemistry translated into loving drugs. I started studying drugs in a vacuum, practically absent of other knowledge about the human body. I learned about the functions of the body based on the activity of drugs, not the other way around. This is probably the most detached-from-reality way to go about the process. The people involved were irrelevant. The drugs were cool. They weren't.

Four years later I live for patient care. Not because I necessarily like patients more, although I did discover that I'm not as misanthropic as I thought. No, I live for patient care because patient care is when I'm getting the most out of the effort I've put into learning things. Not being able to do patient care would be like telling a carpenter that he needed six years of school to get licensed but that on the job all he'd be allowed to do is hold the toolbox and make sure that the boss was using the right tools.

But N.B., you're thinking, TAP didn't say patient care was unimportant or bad. He said it wasn't profitable. "Patient care" doesn't pay the bills. Dispensing prescriptions does.

I agree that somebody does need to be paying attention to whether or not a business is making money. I don't ever want to be that person. That's why I would never start my own pharmacy, although I considered it at one point (it's also business suicide in today's climate, but whatever). I want to take care of patients without being worried about whether or not I'm filling enough scripts per week to pay my overhead, and if that makes me an empty-headed pharmacy student, so be it. Because if script volume is the most important indicator of whether or not I'm doing a good job then I am not a clinician, I'm a salesman.

Modern big-box stores and corner pharmacies are taking a loss on operating their pharmacy departments. It's the honest truth. The money is made elsewhere. How else could the big-boxes justify giving away generics at $4 or select antibiotics for free? They know the pharmacy doesn't make money; the pharmacy attracts customers. The pharmacy is not making money no matter what. What you are doing by filling more scripts is not making money, it is losing less money.

TAP's opinion on this subject is that the solution is to target the PBMs, or pharmacy benefits managers, that screw pharmacists over by reimbursing them considerably less than what they deserve. A business cannot operate by selling its product at a loss, but the PBMs essentially say something like this: "Well, you collected the patient's $10 copay and you charge uninsured patients $150 for the drug? It costs you $120 to order the drug? Yeah, we'll give you $90 + $3.50 for the dispensing fee, take it or leave it." Fix the industry regulations that let the PBMs get away with robbery and we're all good.

Because I'm young and naïve, I'm too stupid to know my ideas are bad. So here's mine. Pitch out the idea that pharmacy is a business altogether. Fuck pharmacy entrepreneurship. Stop assuming that pharmacies should operate as "drug sellers" and start thinking of them as "drug providers." The old business model doesn't work anymore. No longer does Joe the Pharmacist open his own shoppe on the corner and grind powders with a mortar and pestle all day so that he can punch capsules or roll pills. Nobody sells patent medicines anymore (unless you count the altmed scammers). Pharmacy is now ruled by giants, not Joes.

We should turn pharmacy over to the ultimate giant--the Feds. No more corpo-pharma. Pharmacists become government-salaried employees. Prescription drugs (not OTCs), patient care, whatever, they all become services funded by your tax dollars, free or practically free depending on your income level. Pharmacists already counsel for free. They're already giving away their services without collecting a dime--because it's viewed as a professional responsibility. The only thing stopping them from giving away the drugs is the perception that it's necessary to make a profit because no one will keep you afloat otherwise. Currently, that's true. But it doesn't have to be.

Laugh if you want, call me a socialist (the ultimate bad word), whatever, but at least have the courtesy to tell me why you think it wouldn't work. Spain has a system sort of like this. Germany has its own version. A lot of European countries have variations on this model; even if the pharmacies aren't government-owned, public healthcare provisions cover the cost of patient care. Clearly the government is not expecting pharmacies to "operate at a loss." If it did, the pharmacies would go out of business and there would be be no more pharmacies, which is a rather self-defeating model if the purpose of having universal health coverage is to make sure people have access to care.

I know I'm committing the error of "is versus ought" here, saying all this. But that's okay. The current fight in pharmacy is trying to keep pharmacy a working "business" under the present model. We'll never win. Pharmacy is too big now for Joe pharmacist to contain its girth. The business end of pharmacy needs to be abandoned altogther in favor of a patient-focused model.

Here's the bottom line. If you operate a pharmacy (or a doctor's office, for that matter) like a business, profit must trump patients. This is contradictory to every code of medical ethics in existence. It's true, you might take some patients at a loss in "real" practice. But there still exists a conflict of interests; as long as pharmacists are concerned about keeping a roof over their heads and worried about "the bottom line" they will never be giving 100% to the patients they serve. Healthcare is a service field. It is lucrative for many people. But ideally the point of being a doctor or pharmacist is not to get rich. It is to help people--and be sufficiently compensated so that one can live comfortably during his "off hours."

Don't recoil reflexively when someone says "socialist" or "government-subsidized." Abandon the idea that individualism--i.e., capitalism--is the best solution. You can't even start your own pharmacy anymore and have it survive; claiming that starting a pharmacy is a sound business idea at this point is utterly foolish. Quit thinking about you and how you want to run your own business which is the American dream. Stop being a selfish prick and put your patients first!

And if that's not why you went into healthcare, leave. Because we don't want you here.

Thought Experiment

What if more things worked like health insurance?

INT. A FIREHOUSE AT NIGHT.

DISPATCHER sits over a bank of computer terminals, nervously adjusting his headset. He reaches for a volume dial. CHIEF sits at a table in the background behind Dispatcher, nursing a cup of coffee.

DISPATCHER: Chief, we're getting a call. It's the Taylor house on 38th.

CHIEF: Mmm. That's too bad. Nice place. How's their coverage?

DISPATCHER: They don't have any, sir. Their policy was cancelled two months ago when Mr. Taylor was laid off.

CHIEF: What!? They didn't bother to get private coverage? How irresponsible can Mr. Taylor be?

DISPATCHER: Well, they said they couldn't afford the premiums. And Mr. Taylor is a smoker. You know what that does to rates. Besides, with the deductibles on the private plans, they'd have to burn down two houses before we picked up anything.

CHIEF: Yeah, you're probably right. Well, that settles it. We can't afford to respond. The risk of not receiving payment is too high. We can't operate a business like that.

DISPATCHER: Too true, sir. Actuaries are in full agreement. And the initial assessment is sound. The house is too far away from neighboring property for the fire to be contagious. It'll burn itself out without any trouble.

CHIEF: Oh, good. No worries about liability. I'll take the call. (dispatcher presses a button on the console) Mrs. Taylor? I'm sorry, but we're just going to have to let your house burn down.

MRS. TAYLOR's voice breaks in over the intercom.

MRS. TAYLOR: (clearly distressed) But...my baby is in there! You have to save my baby!

CHIEF: I'm sorry, ma'am, but we just can't help you. Why don't you call the emergency fire department? They're required by law to come help, even if you don't have coverage.

MRS. TAYLOR: But everyone's calling the emergency fire department lately! It could take them hours to get here!

CHIEF: Well, Mrs. Taylor, I'm sorry to say this, but we wouldn't have that problem if people would just be responsible and make sure they always had fire insurance. This is America, and people have to be willing to be accountable for their own bad decisions. We can't make the taxpayers bear the burden of a few careless people whose houses catch on fire. (he coughs) Especially smokers like your husband. It's just a disaster waiting to happen.

Mrs. Taylor continues to weep in the background. The Dispatcher and Chief exchange glances, shrug, and terminate the connection.

DISPATCHER: I really think that the free market has done wonders for the firefighting industry. We spend so much less time answering unnecessary calls.

CHIEF: It's like my father always said. There's nothing that can't be improved by privatization. Who wants the government interfering with our lives?

DISPATCHER: Yep. Besides, there's no "right to firefighter services" listed anywhere in the Constitution. America really has become a nation of whiners.

CHIEF: You said it. You want a cup of coffee?

DISPATCHER: Cream and two sugars, please.

New and Improved! Now With Even MORE Sodium!

Er, wait a minute, I'm not advertising Grandma Georgia's Lard-o-hardtack, I'm throwing Mike the Mad Biologist another set of major props.

There's just no way I could've said it better myself. Mike is nailing this healthcare thing lately.

...the key point is this: people don't want exciting 'health insurance products', they want adequate care when they are sick. Also, how are we supposed to choose the 'right' healthcare...

...none of us have any way to evaluate if the insurance we have picked will provide the healthcare we need if something disastrous (or even mildly annoying) strikes. I have no idea if something bad happens (and there are many kinds of 'somethings bad') whether my plan will provide the healthcare I need. Would I have access to the specialists I might require? Which treatments would be covered, and for how long?

Tonight, I raise my scotch glass to you, Mike, for a succinct and elegant explanation of everything that's wrong with McCain's vision of healthcare.

Also, Chuck Dupree, a commentor on Paul Krugman's blog, has hit the nail on the head and driven it through the board with one swift stroke:

Add me to the list of those who can’t figure out why we’re talking about insurance. I don’t want insurance. I want health care, and I don’t see why insurance companies should be involved.

Caveat Emptor: Drugs and the Free Market

First reported (within my circle of sources and reading material) by PalMD of denialism blog, the FDA is cracking down on the sale of many unapproved "cancer cures" being sold online and elsewhere. This, in itself, is excellent.

It is also a fantastic example why trusting the free market to solve all problems is a completely bogus idea.

I always come back to healthcare whenever I want to talk about the free market. This is partly because healthcare is what I know; I am much more capable of talking about the prices of drugs (in particular) and medical services than I am talking about the prices of various other products because I'm surrounded by them. But, more importantly, the healthcare "market" is a spectacular example of an area where "natural market forces" are completely insufficient regulation.

The short answer for why this is is that the costs of healthcare services are not always clear up front, so there's no way to "comparison shop." You usually get treated and worry about how much it will cost later, especially in an emergency situation. The capitalist model of self-regulation requires consumers to be able to discern the cost of services in order for it to make any sense. How can you be an informed consumer if you can't evaluate the cost or the utility (worth) of goods?

Sure, this is true on some massive scale when we talk about hospital stays and surgeries, but the problem with those is that the only consumers who actually know what they cost are already bankrupt because of them (everyone else is insulated from the scary truth of the real costs thanks to insurance companies). But those are the big-ticket items of the healthcare world. And you might argue that in some cases that they're often essential to the point where price is no object, because most people would rather pay any amount of money than die. (They might regret this decision later when they're being suffocated by hospital bills, but few rational people are going to say "nah, let me die, saving my life will cost too much.")

So let's talk about small out-of-pocket expenses of non-urgent matters.

Buying drugs is, in many cases, like buying any other good. There exists genuine competition in the market, especially when we're talking about non-prescription items. Should I buy Alavert or Claritin? Benadryl or the "store brand?" Which pain reliever do I choose? The fact of the matter is that 99.9% of the time all of these goods are equal. It doesn't matter, from a medical perspective, whether you buy Claritin or Alavert. They're the same drug. The only reason consumers might prefer one over the other is because of advertising and brand recognition--this is a "Coke or Pepsi" scenario.

Most consumers know that Coke and Pepsi are equivalent products (more or less). Sure, they might have a preference for one over the other, and that preference might even stand up to blind taste-tests. But how many consumers really know that the "store brand" is as good as the brand name when it comes to drugs?

If marketing research is any indication, the answer is not many. In 2005, generic versions of OTC drugs made up only 23.4% of the market share. Conversely, generic prescription drugs made up over 75% of the market share. Hmm. Why might this be?

When filling a prescription, most pharmacies will automatically substitute the generic if one is available as long as the physician has indicated that such a substitution is acceptable. Some states (Massachusetts, for example) actually mandate substitution unless the physician indicates otherwise. It's easy to see why generic prescription drugs predominate the market. Many commonly prescribed drugs are more or less only available as generics; the brand names are no longer made or no longer carried by pharmacies (how many people really care about getting brand name Amoxil?). I think it is safe to say that one major reason generic drugs predominate in the prescription drug market is that patients are not actively involved in the brand versus generic decision. They are leaving the decision to someone who is more educated about the product they are buying. The doctor and the pharmacist both know (and will reassure the patient if necessary) that the generic is just as good as the brand for a fraction of the cost.

Letting your pharmacist substitute a generic to save you money is kind of like getting insider information on stocks or letting your broker decide where to invest your money. You're not stupid for consulting your broker. You're smart. You're using your broker's expertise to your advantage. He probably knows a lot more about the stock market than you do, and you will make more money if you let him help you.

There's also the fact that the price difference between brand and generic in the prescription drug market is pretty large. Consider lisinopril, a drug used to lower blood pressure, prevent recurrent strokes, and protect the kidneys of diabetics. Generic lisinopril costs about 50 cents a tablet. The branded product costs twice as much. Cholesterol-lowering simvastatin's (Zocor) generic is about $2 per dose. The brand is about $5. Does it really make sense to pay twice as much for something if you don't have to? Of course not. Consumers aren't stupid.

The short story is that about 75% of consumers, given what amounts to "expert advice," will pick the cheaper prescription drug product. So why do only 25% of consumers pick the cheaper generic when making an OTC drug purchase?

The same reasons why they would choose a branded drug if there weren't a pharmacist between them and their prescriptions.

Brand reputation. Perception of generics as inferior products--misconceptions about quality, purity, and efficacy. Prior "bad experiences" with a generic drug. Inability to pronounce the generic drug's name (yes, I'm serious). And people are suspicious about the origins of "store brand" drugs. I'm not sure where people think they come from--they're made in the same factories and held to the same manufacturing standards as the brands.

There's limited standardization in naming generic OTC drugs. Because drug chains can't rely on brand recognition the same way ("Claritin is for allergies, I saw it on TV") most generic OTCs have very...generic...names. "Non-drowsy allergy relief." "Non-aspirin pain reliever." "Stomach acid relief." I kid you not when I say that there are probably half a dozen products on a given pharmacy shelf that have some variation on the phrase "cold symptom relief" as their only name, leaving the consumer to decide which product to purchase.

If the consumer does not first consult an "expert" (the pharmacist), they is left using the same reasoning tools that affect their decision about brand-name drugs. Anecdotally, I would say that most consumers don't know the active ingredients in their preferred OTC cocktails. They know the color of the box. They know what the product is called. And, most important to the consumer, they know what worked last time they were sick. They want that again, whatever it was, even if it's the wrong drug for the symptoms they have this time.

(Walgreens is brilliant in this regard by shoving the "Wal-" prefix in front of all their generic names. I get a lot of people who ask me for Wal-itin. I don't work for Walgreens. Our Claritin generic is obviously called something else. Many of them don't even seem to realize that Wal-itin is Walgreen's name for their Claritin generic--they think Wal-itin is its own unique drug, brewed in some secret Walgreens facility.)

The price difference between brand and generic OTC drugs seems smaller, which is another major factor. A box of 50 Tylenol costs $6.50 at Walgreens. A box of the generic costs $4.50, $2 less. Normally, when someone offers you the same product at a lower price, you take it. The generic market should be totally destroying Tylenol sales, but McNeil Consumer Healthcare still sold $129 million worth of their flagship product, "extra-strength Tylenol tablets," in 2003. That doesn't include sales of the popular Tylenol PM, Tylenol Cold, or liquid Children's Tylenol. The sum for all these product lines from 2003 is about $242 million.

Think about that for a second. Consumers spent an average of $2 more per purchase to buy products with the Tylenol brand name so frequently that McNeil made $242 million dollars. And they did it for the reasons I've already mentioned above--or perhaps others. Marketing experts spend their whole careers trying to understand and capitalize on this stuff; my understanding of it is very basic.

This isn't like buying generic foods, where you might get something you don't like as much as the brand product. The generic drug industry is tightly-regulated by the FDA. You can't sell generic drugs that are inferior to the brand names, unless your definition of "inferior" is different from the FDA's. The drugs have to work just as well.

You could argue that consumers might be buying the brands over the generics because of factors other than how well they work as drugs. Sometimes brand name drug tablets have coatings or flavorings that make them taste better than their generic counterparts. Maybe the packaging is easier to open. Some people are legitimately allergic to certain dyes or additives that might be present in the generic that aren't in the brand (but this is extremely rare). But this probably wouldn't account for 75% of consumers choosing brands over generics.

No, the short answer to why consumers choose branded products when buying OTC drugs is that they don't actually have all the knowledge necessary to make an informed purchase.

Man, that was long-winded. Let's come back to the original point of the entry.

If consumers aren't making informed decisions about whether to buy brands or generics when making OTC purchases, who the hell thinks that consumers will be able to make informed decisions about how to treat their own cancer?

I'm not talking about violating patient autonomy here. Patients should never be forced to accept treatments against their will. Patients should talk with their physicians and discuss treatment options, then choose whatever they feel is most acceptable. But it is up to the doctor--who has many more years of education on the subject--to lay out the options. If the patient believes that there is an option that the physician has not mentioned, he or she should certainly bring it up.

But when physicians say "no, I don't think that's a good idea," the answer is not to go ahead and do it anyway. By all means, ask for a second opinion. You're entitled to one. But do not decide that somehow you are more qualified than a trained oncologist to choose your own cancer treatment. You are not. Ignoring the advice of experts to pursue the beat of a different drum to your own detriment isn't individuality. It's idiocy.

This is why holding up "freedom of choice" when talking about unproven (and often highly suspect) treatments for cancer or any other disease is a bullshit move intended to distract from the real issue at hand. Your doctor telling you that herbal tea will not cure your cancer is not oppression. Shutting down salesmen who commit fraud isn't oppression, either.

But in the worldview of the champions of truly deregulated free-market medicine, the consumer is granted a delicious variety false empowerment. You have the right to choose any treatment you want--even those that don't work. And if you choose treatments that don't work instead of those that do, well, caveat emptor. May the buyer beware. All sales are final and non-refundable. The only person you have to blame for getting scammed is yourself. And this is disgusting.

So go ahead. Fight for your freedom to get ripped off. The primary characteristic of the free-market is that it's self-correcting, right? Frauds will eventually be exposed and people will stop buying their products.

But how many people should be allowed to die before we say "enough is enough?"

Doing the Minimum

So I managed to get myself into a dispute with someone in another arena about the minimum wage. He seemed to think that the free market would sort everything out equitably if we eliminated it. (He also provided no data to support this assertion. I have to charitably assume that he thinks this will be the case because he just has that much faith in humanity to "do the right thing.")

I'm not even going to touch that, but someone came along and attempted to defend Mr. Free-market's viewpoint. At the end of his post, he posed a philosophical question of sorts. What is the intent of the minimum wage?

I think that the "intent" of the minimum wage is to make sure that employers aren't paying employees less than they are able to live on. I decided to dig up some information on the subject.

The Economic Policy Institute has an interesting calculator that lets you put in typical family structures and locations to calculate a "basic family budget." The budget only covers the cost of food, shelter, and clothing. It includes "no savings, no restaurant meals, no emergency funds--not even renter's insurance."

I decided to calculate the cost of living based on two parents and one child for Indianapolis, Indiana. I myself live in Indianapolis, so I can tell you exactly how much I pay to live here for comparison. I live with three other roommates and we all pay equal shares, but we also all earn wages and are employed at least part-time (I work about 10-12 hours a week). I am also lucky to have parents that pay some portion of my expenses (I am a full-time student). Unless stated otherwise, I am only listing my share. To estimate the "actual" cost, multiply by four.

• My monthly rent is $1000, of which I owe 1/4 (I have roommates) for a total of $250/month.
  
• I spend about $125/month on groceries.
  
• My basic utilities cost me about $150 a month.
  
• I also have phone and internet access that costs me $12/month.
  
• I don't pay my own car insurance, but I decided to estimate it by getting a quote from my insurance company. Basic coverage would cost me $100/month.
  
• Gas to operate that car currently costs me about $45/month.
  

Total: I spend $632/month for my barest necessities, not factoring in entertainment or savings, which amounts to $8,184 per year. It also doesn't include health insurance, which I have through my family. I suppose I could tack an extra $75/month on for a health care plan that basically doesn't cover anything--that's what my girlfriend has (and a $2500 deductible, to boot). If I had to pay everything myself it would cost $32,736 per year. None of this accounts for my $30,000/year education, which I can only pay for because the government is subsidizing some loans and I have a small scholarship.

The budget calculator suggests the following monthly expenses for a family of two with one child living in my city:

• Housing: $726
  
• Food:: $514
  
• Child care: $542
  
• Transportation:: $447
  
• Health care: $286
  
• Other necessities: $298 (I assume they mean toiletries, clothing, etc)
  
• Monthly taxes paid: $377
  

The monthly total is $3,189 and the annual total is $38,273. I have zero problems believing that this calculator is accurate at estimating the cost of a family of three living in Indianapolis.

Indiana's minimum wage is $6.55/hour as of July 24th, 2008.

$6.55/hour x 40 hours/week x 52 weeks/year means that if you take no unpaid vacation, get no overtime, and work every day you possibly can you make $13,624 per year in Indiana. If you are married or in a domestic partnership and your spouse has the same earning potential you will therefore make $27,248 per year, before taxes.

You are about $10,000 short.

As far as state taxes go, Indiana has the third lowestindividual income tax rate of any state as of 2007. Federal income tax for this family will be filed jointly (let's assume they're married). For reference, here is a tax bracket calculator. They make between $16,050 and $65,100, so they pay 15%, or $4,087. But hey, they get it all back, right?

In short, anyone arguing that the minimum wage is actually sufficient to live on clearly hasn't done any math lately. How is the average American family supposed to live with a $10,000 budget deficit? And that's without any recreational expenses. No movies, no restaurant dinners, no mommy-and-daddy dates, no alcohol or tobacco purchases. The answer is that they borrow it, and that's where we get into trouble.

Here's the thing. You have to be a dreadfully callous human being to say that people who work minimum wage jobs (mostly those who didn't or can't get a college education) don't deserve a living wage. Should people with more education make more money? Of course. But should people with only a high school diploma be paid less than they can afford to live on?

Seeing the Forest for the Trees

I have mentioned my aggravation with Forest Pharmaceuticals before in the context of their excessive promotion of Namenda, a drug to "delay the progression" of Alzheimer's disease. While Namenda is effective, the drug reps I've talked to have a tendency to really push it as being significantly better than it actually is, especially since we're looking at doubling the cost per patient and increasing "pill burden" for patients or their caretakers. There's nothing more depressing to me than seeing families spending a fortune on medications for Alzheimer's while watching their loved ones deteriorate despite treatment.

On the other hand, Forest's Lexapro is a follow-on drug that's actually been demonstrated to be better than its parent. So maybe they aren't all bad.

Then they released Bystolic.

Bystolic is a beta-blocker. The market is positively overflowing with beta-blockers. Metaprolol, atenolol, propranolol...a dozen or more drugs. Granted, they have subtle differences, but Bystolic doesn't bring anything new to the table.

Beta-blockers reduce adrenergic (adrenaline-mediated) stimulation of the heart and blood vessels, slowing heart rate and dilating arterioles to decrease blood pressure. B-blockers aren't as good at lowering BP directly as some other drugs, but they are quite useful in preventing further damage to the heart after a myocardial infarction (heart attack) and in treating irregular heartbeats. Intriguingly, propranolol can even be used to prevent migraines, though the precise mechanism of action is not well-understood.

Bystolic is only approved to lower high blood pressure, but Forest is hoping to get it approved for patients with heart failure as well. Unfortunately for Forest, we already have a great cousin drug that has both indications--carvedilol--and it's available generically as of last year.

I realize that sometimes drugs get stuck in the research pipeline and the company gets so far into development that not releasing the drug is a bad financial move even if the drug is not likely to "sell." But Forest has likely spent enough money producing Bystolic that they must find a way to get physicians to prescribe it despite the fact that Bystolic is a "useless" drug. Sure, it works, but no sane clinician is going to prescribe it given a myriad of equally effective alternatives that cost one-fourth as much.

Unless, of course, Forest sends out their reps to promote it. Which means that it's a safe bet that Forest is going to spend a lot of money to advertise a drug that you'd have to be incredibly foolish to prescribe. Drug research and development costs are very high, but pharmaceutical advertising inflates prices beyond what is reasonable. And if given a sufficiently convincing sales pitch, many physicians might prescribe the drug anyway. Many doctors just don't know how much drugs cost. I have personal experience in the matter; I make a lot of phone calls when I'm working to ask physicians to switch to cheaper alternatives or to permit generic substitution when they've signed something "dispense as written" for no good reason (dermatologists, I'm looking at you).

Come on, Forest. You can do better than this. I know I saw your vague, almost viral ads in pharmacy magazines and got a little excited about your "new development in the treatment of hypertension." At least throw us another direct renin inhibitor instead of trying to pass off a totally underwhelming drug as the next big thing.

Pharmacy is Not a Commodity!

Pharmacists and Corpo-Drugstore are intertwined in a sort of Faustian bargain.

There's not a lot of glamour in community/retail pharmacy. CorpoDrug pays pharmacists lots of money to stand behind a counter. The fact that "patient" and "customer" are used interchangeably to refer to patrons of CorpoDrug's pharmacy is very telling; I find it most interesting who chooses to use which word. As an informal observation, most pharmacists prefer patient. Most technicians and store managers use customer. Sapir and Whorf may be onto something here. Patient sounds a lot more "medical." Calling patients customers reinforces the idea that CorpoDrug is a store. I would quip about portraying pharmacy as the equal of the Big Box retail business here if it weren't for the fact that such a comparision is pointless; Wal-Mart, Meijer, Target and CostCo all have their own pharmacy departments.

The problem is not that CorpoDrug is turning pharmacists into glorified store managers who coincidentally have medical degrees. The problem is that pharmacy started that way and that it has failed to break free of those chains. CVS retail outlets originally did not include pharmacies; the "CVS/pharmacy" nomenclature grew out of a need to inform consumers which locations had pharmacies and which did not. Walgreens began as a drug store, but this was back in the era where the drug store was a place to get malted milkshakes and tobacco products. The history of community pharmacy suggests that with the advent of pharmaceutical manufacturing and the downfall of compounding that pharmacists filled no clear niche in the healthcare field. Now, pharmacy is rapidly evolving into a profession of drug information and medication therapy management experts. Pharmacists in hospitals and managed-care facilities have the opportunity to work with other healthcare professionals to optimize patient outcomes by contributing their unique skills and knowledge as drug experts. Physicians can rely on pharmacists as valuable allies.

But CorpoDrug is still living in the stone age of pharmacy, perhaps with fewer mortars and pestles. It is two-faced, talking out of both mouths simultaneously about the value of its pharmacists. Surely it "values" pharmacists in the sense that CorpoDrug is willing to pay them a median salary of $90,000. And the American public, at least, considers pharmacists to be among the most ethical professions, just behind nurses. It is clear that people think that pharmacists are ethical. And if my experience is any indication, they think pharmacists are knowledgeable, too. Pharmacists get asked some pretty crazy questions, like whether or not sodium benzoate is safe or which urinary tract infection test strips are more reliable. This is in addition to the more traditional queries like "can I take these two medications together?" and "how much Tylenol should I give my four-month-old?" A big part of why pharmacists get used so frequently as a source of information, aside from the public's assumption of their ethics, is their accessibility. I can think of few doctors who have time to take phone calls about sodium benzoate, but pharmacies do it all the time.

A district manager for the retail pharmacy that employs me stopped into our store one day and was conversing with the pharmacist. "We're here to help people," he said, "but pharmacy is a business, too." In the most base sense, this is true. It isn't wrong to want to make money; it's a necessity of living in a capitalist society, and there is nothing immoral about that in itself. From a marketing perspective, prescription drugs are a commodity. The time and advice of a pharmacist is a commodity. These are goods and services for which there is a demand and only a limited supply. But healthcare professionals, the dedicated, honest, ethical ones at least, don't see their services as commodities, not in the same way that businessmen do. Can you imagine a physician offering to push people to the front of his waiting list for appointments if they volunteered to pay higher fees? Would an ethical doctor provide patients with prescriptions for whatever they asked for on-demand as long as the patient was a paying customer? These might be very profitable business moves for a physician. Assuming he evaded prosecution, a physician willing to "sell" prescriptions for drugs of abuse could make a huge fortune. But it would be illegal, and more importantly, unethical.

Pharmacists, like physicians, take an oath. Nowhere in that oath is "I will uphold a committment to the idea that the customer is always right" or "I promise to provide the lowest prices for antibiotics in town." The first point is "I will consider the welfare of humanity and relief of human suffering my primary concerns." Pharmacists are professionals.

The mechanisms that CorpoDrug use to secure customers are insulting. Gift card coupons that encourage patients to bounce back and forth between retail chains whenever they get a new piece of junk mail. My chain is currently offering as much as $50 in gift cards for filling a new or transferred prescription at our chain instead of somebody else's. "Ten minutes or less" guarantees that any reasonable pharmacist will recognize as total bull; if your insurance company is being a pain or your doctor's handwriting is illegible, I'm not going to uphold some fast-food speedy service ideal at the expense of patient safety. Drive-through windows are perhaps the most appalling of all; they suggest that the time and expertise and pharmacists aren't even worth getting out of your car. I'll be amazed when a physician's office puts in a drive-through and volunteers to diagnose patients through the window. Once you've got your diagnosis, you pull up to the second window to pay and get your prescription. Absolutely absurd.

CorpoDrug treats pharmacy like a commodity, and the public has picked up on the idea. Pharmacies, like McDonalds' outlets, are interchangeable. I have dozens of stories about patients who were in my store and thought they were at a different retail chain. All pharmacies have the same drugs, right? Perhaps pharmacists are interchangeable, too, like grill cooks, as long as the product is the same. CorpoDrug uses one mouth to say that pharmacists should take the time to counsel patients and verbally slaps them on the hand for "unacceptable" wait times that cause loss of profit margins with the other. It becomes the job of individual pharmacists to uphold high standards of care--with or without the support from their retail outlets. Many find it impossible to keep up and have simply folded.

A lot of patients on chronic therapies, namely insured patients, will pick one pharmacy and stick with it, giving the pharmacist or pharmacists who work there a greater degree of access to their medication history. Programs to encourage these patients to stick with one pharmacy, or at least one chain, have been largely successful. On the other hand, there are the patients who comparison shop, bouncing back and forth between outlets based on who has the cheapest prices for each particular medication. This spells disaster when the patient winds up on two drugs that should never have been taken together.

Which brings us to universal healthcare. Pharmacy wouldn't have to be a commodity in the face of universal healthcare--we could have universal pharmacies, too. Instead of walking past displays full of toilet paper and office supplies on the way to the pharmacy "department," the whole structure could be dedicated to health. With adequate staffing, patients could make appointments to speak with pharmacists about their medication--a service that is already being promoted for Medicare patients. Imagine if every corner drugstore offered the same service and advertised it as heavily as they do sales on toothpaste! The sort of competition CorpoDrug engages in with PharmaMart is bad for patients, whether they realize it or not; they become sources of revenue rather than sick people, permitting greed and capitalism to steamroll good health practices in the face of profits. CorpoDrug doesn't sell dietary supplements because they help people. They're on the shelves because they add to CorpoDrug's profit margins.

My absolute least-favorite "pharmacy" publication is Drug Store News; sure, they talk about clinical issues from time to time, but a huge portion of Drug Store News is things like "which brand of lip balm sells the best?" and "how can I add proprietary vitamin blends to my inventory to boost earnings?" It's positively revolting. If drug stores were really focused on being healthcare providers, this sort of crap would never propagate. Physicians don't distribute coupons through the mail. That's the shady realm of chiropractors. Would physicians subscribe to publications suggesting that they add in-office plastic surgery or proprietary herbal blends to their services to supplement their incomes? Absolutely not, and most physicians would be offended at the idea. Why do pharmacists put up with it? The short answer is that most of them feel that they don't have a choice. Independent pharmacies really do need to go to extremes to keep from being washed away by the tsunami generated by the chains. And pharmacists employed by those chains are essentially being bribed into silence with high salaries.

Pharmacy is not a commodity. Medical care is not a commodity. Medical care is a necessity, a basic human right. And if pharmacy is going to contribute to overall human health for our communities, it's going to be necessary for pharmacy to distance itself from "business" as much as is humanly possible. Pharmacists need to support themselves and their families, and it's easy to see why a desperate pharmacist, buried in debt and student loans, would sign on with CorpoDrug in order to dig their way out. But if CorpoDrug really had any respect for their pharmacists and their clinical expertise, they wouldn't treat them the way they do.

Corpo-Pharma's assault on pharmacist ethics persists.