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    Friday, June 5, 2009

    Preventive Medicine—Only If It Is Profitable?

    We’ve all heard—at least in this column—that medical insurance carriers favor clinical guidelines to “improve medical quality care.” Cynical doctors maintain that all the insurance companies want to do is to make more profits or at least not take more losses; and they also want high Wall Street share values.

    So, maintain the cynics, if the clinical guideline saves money—the insurance companies are for it. If on the contrary it will lose money, they’re against even though in the long run it will improve the quality of medical care.

    I have always disputed these cynics on the basis that there would have to be a conspiracy to do this; and a conspiracy sooner or later gets exposed.

    Now I read in the New York Times (5/5/09, B3, Pollack) "In a setback for the fledgling field of personalized medicine, Medicare has decided not to pay for genetic tests intended to help doctors determine the best dose of the blood thinner warfarin." Warfarin, also known as Coumadin is used for patients so that clots take a longer time to form and thus to obstruct vital arteries and veins.

    It is also used as a rat poison because it can be lethal at high doses and cause massive hemorrhage—in rats and humans.
    The dose and amount of Warfarin has to be closely titrated to the patients’ prothrombin time or INR initially at least every 1-3 days to make sure the dose is not set too high.

    The new warfarin response tests, which cost $50 to $500, look at variations in two specific genes in a patient. They are among a group of new tests that seek to tailor medical treatments based on a patient’s genetic makeup. Such tests help tell which drug would be best for a particular person, or whether a patient might be susceptible to dangerous side effects. Studies have shown that using the genetic test also might allow the proper dose to be achieved more quickly and more safely.

    The Centers for Medicare and Medicaid Services (CMS), in a proposed decision posted on its website stated that “While some research has suggested that using the genetic test might allow the proper dose to be achieved more quickly, there was little evidence that doing so translated into a lower risk of blood clots or hemorrhages."
    This is true.
    It would take a lot more studying with a lot more patients-- up to several more years to establish the final evidence that using these tests expedite better outcomes in patient care.

    But the Times adds an important fact-- that "the Food and Drug Administration recommends, [but does not require], a genetic test for patients starting on warfarin."

    Medical societies are divided on the issue.

    Since the Food and Drug Administration recommends, but does not require, a genetic test for patients starting on warfarin this might also become a medical malpractice issue in which a plaintiff can complain that the doctor guessed wrong on his clotting estimate and should have done the test before starting the patient on Warfarin.

    To be fair there are, however, there are various practical problems with the warfarin genetic tests.

    The test results often do not come back fast enough. And simply knowing which variants of the two genes a patient has does not automatically tell the doctor what dose to give. That depends on other factors as well.

    Moreover, use of the genetic tests does not eliminate the need to periodically test the patient’s blood-clotting propensity.
    But this much is certain, say the cynics. If someone can show them that it saved money the insurance carriers would be picking up the tab a lot sooner.
    Another Preventive Medical Step Goes Unpaid

    On yet another but similar issue, more physicians prescribing exercise plans as preventive measures for patients. Exercise is prescribed to the more than 47 million of people who have metabolic syndrome"— i.e. at least three of these five risk factors: excess abdominal fat, abnormal triglyceride levels, elevated blood sugar levels, high blood pressure and diabetes -- the forerunner of coronary heart disease as well as a whole host of costly degenerative diseases. These patients already spend more than $300 a month on prescriptions. The Agency for Healthcare Research and Quality reports that in 2006, Americans older than 18 spent $38 billion on prescription drugs that lower cholesterol and control weight and diabetes. They spent an additional $33 billion on cardiovascular drugs such as blood pressure medicine.

    The Washington Post (5/5/09, Gregorian) reports that currently, "insurance usually covers" exercise ONLY "as part of rehabilitative programs for patients who've had heart attacks, undergone coronary bypass surgery, or experienced other cardiac problems." But a growing number of doctors nationwide are prescribing detailed exercise plans as a preventive measure before the health of high-risk patients deteriorates.
    And they'd like to see insurance cover those patients as well. That's where physical therapists and such programs such as Fitness First, at St. John's Mercy Heart and Vascular Hospital in St. Louis, with similar teams in a lot of other medical centers in other cities can play an important role. With these rehab organizations, a team of exercise specialists and nurses helps patients build confidence and teaches high risk patients to exercise effectively and safely. These programs are priced at about $45 a month, is NOT covered by plans.

    Cynics say that this is where the insurance carriers are totally nearsighted.
    They sometimes cannot see the forest for the trees. And their Wall Street owners are more interested in short term profits than on long term gains—because that’s what sells stocks.

    Live interview Monday, June 8th 11AM, ET with Sybil Tonkonogy on WNTN (AM 1550), Newton, MA. Interview will also air live on radio's web site,

    Please remember, as with all our articles we provide information, not medical advice.

    For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

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