Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.
The Undue Strain Of Dialysis
This is criminal, and the dialysis companies are not the only ones plundering the public (“Bill Of The Month: First Kidney Failure, Then A $540,842 Bill For Dialysis,” July 25). If you have no medical insurance and go to a doctor or hospital for medical care, you get charged tenfold what they accept from insurance companies. No properly run health care facility or doctor is losing money by accepting the agreed fees that the insurance companies pay. It’s absolutely outrageous to charge people who can least afford to pay up to 10 times the insurance charges. This scam has existed for decades and Congress has done nothing to protect consumers. My understanding is that no other country allows this discrimination against the poor. It’s time this outrageous exploitation of consumers be terminated.
— Jorg Meister, Middlegrove, N.Y.
Tools like this are, unfortunately, necessary to navigating the bewildering process that is trying to obtain medical care.
— David W.S. Lieberman (@DwsLieberman) July 25, 2019
— David W.S. Lieberman, Somerville, Mass.
This is in response to the bill of Sovereign and Jessica Valentine. It is ridiculous that Fresenius can charge them $14,000 per session when dialysis in Mexico using the same dialysis machines and procedures runs $400 USD per session. I take my mother there frequently for vacation, and we pay cash for her dialysis sessions.
—Martina Patella, Oakland, Calif.
This is just insane. How can this happen in a so-called first world country?
— Andrea Hilderman (@northarcagri) July 26, 2019
— Andrea Hilderman, Manitoba, Canada
I was appalled to read your article on dialysis. I have a dear friend who built, opened and now operates a dialysis center in Thessaloniki, Greece. His father is a kidney specialist of 30+ years. He wrote the string below about dialysis in Greece when I forwarded the story to him:
“If you have insurance dialysis is free Zero Gratis The average price that dialysis facilities in Greece charge the Greek NHS is around 136 euros.
If a patient who does not have insurance goes to a dialysis facility, he will be charged around 200 euros [about $223 in the United States]. That will be a great day for the facility.”
— Jerry Efremides, New York City
PBMs Put Patients In A Pickle
Besides the delay of generic drugs to market (“California Bill Would Fight Deals That Delay Generic Drugs,” Aug. 1), the pharmacy benefit managers (PBMs) have deals with the manufacturers, and pharmacies are not allowed to dispense a new generic because the PBM will not allow it to happen. Currently, there are Medicare plans that will not pay for generic Ventolin or Advair and demand that we dispense the brand name. It costs patients more, the plan more, and pharmacies lose by dispensing the brand-name drugs.
— David Smith, A & O Clinic Pharmacy, Salinas, Calif.
Winning The Match Game
This is not news (“American Medical Students Less Likely To Choose To Become Primary Care Doctors,” July 3). Medical students have been choosing the higher-end specialties over primary care for decades. I have been in the health care industry for over 40 years and have worked with literally thousands of physicians as an executive at Cedars-Sinai Medical Center and at my two companies, Practice Management Information Corp. and Flash Code Solutions LLC. My daughter and her husband are both radiation oncologists. Board certification in a higher specialty results in higher income and better career choices. Why settle for family practice if you can be an orthopedic surgeon?
— James B. Davis, president and CEO of Practice Management Information Corp., Beverly Hills, Calif.
I think a reduction in the amount of physician time dedicated to administration duties (i.e. paperwork and EMR) needs to be rethought. Although people have high student loan debt, as a doctor we make more than minimal wage so it shouldn’t be the biggest deterrent.
— Jacqueline Ivey-Brown, MD (@JIveybrown) July 9, 2019
— Dr. Jacqueline Ivey-Brown, Chicago
Meds And Momentary Mental Lapses
I read your Navigating Aging column about how many medications affect older adults (“Common Medications Can Masquerade As Dementia In Seniors,” July 18). I am 85 and had two knee replacement surgeries. Every time I have to go to the dentist, I must take four amoxicillin antibiotic tablets one hour before the dentist appointment. I noticed that after I took these antibiotics, my memory became very bad. After a few days, I felt like myself again.
— Janet Gileno, Bomoseen, Vt.
Common Medications Can Masquerade As Dementia In Seniors https://t.co/6gAdUyMCmQ via @khnews – as a geriatrician, I've been preaching this to my patients for years. When I talk to AARP groups and suggest that the "PM" drugs might not be safe, I get dirty looks. Spread the word!
— James Richardson, MD, MPH (@DocRock54) July 18, 2019
— Dr. James P. Richardson, Baltimore
Weighing Costs And Benefits Of Intravenous Iron
I feel your article about iron infusions (“Infusion Treatments — Needed or Not — Can Deplete Patients’ Wallets” Aug. 2) was biased. The article did not discuss the reasons a physician might choose to use IV iron to treat a patient versus oral iron – oral iron is not well tolerated and in the presence of inflammation in the body is not well absorbed. There are blood management programs in the United States that regularly use IV iron to treat anemia to decrease the patient’s risk for a blood transfusion. Although the cost of IV iron differs from one drug to another (the less expensive drugs, such as Ferrlecit, require multiple infusions), when you add up the cost, it includes not only the administration of the drug, but the nursing time and pharmacy preparation time for the medication.
One also must consider the risk for reaction when choosing a particular form of IV iron. Anaphylactic reactions can occur in patients receiving IV iron. Injectafer is one of the drugs we use on a regular basis because other forms of IV iron have a greater risk for reaction. One must consider the added cost of treating an anaphylactic reaction in a patient. Injectafer is a longer-acting form of IV iron; slow-release preparations such as ferric carboxymaltose (Injectafer) are first taken up by macrophages, the shell is digested, and the iron is released slowly over few days as opposed to near-immediate iron release found in other preparations that lead to more adverse reactions.
Although your story provided the experience of a single patient, it did not report the “whole” story about why physicians use IV iron. I receive no incentive for using one drug over another and must consider the patient’s clinical condition and the risks associated with giving IV iron. IV iron will correct iron levels more rapidly in patients because you can give a higher concentration of the drug, versus oral iron, which can take upward of a couple months to improve iron levels. Without really knowing the physician’s rationale for using IV iron in the case of the patient in the article, the author drew conclusions without having all the facts. I agree that we really need to look at health care costs, but the author of the article also failed to mention Big Pharma’s role in driving up the cost of health care.
— David J. Sterken, Grand Rapids, Mich.
Medicare pays $1,600/vial for this. If neither Medicare nor private insurance were involved to “negotiate” for the patient, these would sell for less than $100/vial. What a scam. Infusion Treatments — Needed or Not — Can Deplete Patients’ Wallets https://t.co/wUob0POGwO
— Jim McMullen (@jimmcmullenkc1) August 3, 2019
— Jim McMullen, Kansas City. Mo.
As a Board Certified Oncology Pharmacist (BCOP), hematology/oncology is my field. Our institution used the cheaper iron (Venofer, which, at a low dose of 100 mg, needs to be given more often) for years. Medicare stopped paying for it because the charge was less than $100 — for some reason, the federal insurance program will not bother to pay for lower-cost IV drugs. Seriously. We switched our formulary iron to Injectafer, 750 mg per vial (cost to us ~$100-$750/vial, and the charge to patients per vial is about $1,000 and up), because we were reimbursed by Medicare for the Injectafer (because it is more than $100).
You are spot-on: The USA does not give our healthy iron-deficient patients enough time to benefit from oral iron. We inject IV iron for iron-deficiency anemia even when the patient does not suffer from anything other than bad lab tests.
Most hospitals and ambulatory care centers base their formulary decisions in large part on reimbursement. Medicare cannot bid for drug pricing and does not have a national formulary. This is a serious error on the part of the legislature and costs billions of dollars or more in taxpayer money that goes directly into the pocket of the pharmaceutical industry. Not paying for lower-cost IV drugs is just one very small example. It is terrible for the patients who must bear the cost of this discrepancy.
Reimbursement is a complex issue these days in no small part to the waste of the government.
— Mary Davis, Bellingham, Wash.
Infusion therapy is the tip of the iceberg for costly therapies and surgeries with no benefit to patients. #evidencebasedmedicine must be mandated to avoid fraud, misinformation and misleading patients
— Nicolas Argy, MD, JD (@NicolasArgy) August 2, 2019
— Dr. Nicolas Argy, Boston
Shefali Luthra’s article on intravenous iron is rife with error. The pricing is not close, relative costs are wrong, and the implication of inappropriate use may be correct only based on utterly usurious prices listed.
More than 70% of those prescribed oral iron (PO) report significant gastrointestinal (GI) perturbation, intolerance and non-adherence. PO iron causes diarrhea and constipation, gastric cramping, metallic taste and thick, green tenacious stool. A year of therapy is required to replace stores and correct hemoglobin concentrations, all of which can be done with IV iron in 30 minutes. For people with hereditary bleeding disorders, there is zero credible expectation oral iron can keep up with losses since 10% (maximum) of PO is absorbed and PO raises a protein, hepcidin, which blocks iron absorption for 24 to 48 hours, making adequate repletion unrealistic.
InjectaFer is the most expensive iron. It costs $843 for 750 milligrams. Based on the preponderance of published evidence, a gram of iron in a single dose is about all we can utilize. The recommended dose of InjectaFer is 1,500 mg, $1,686 for a course (not vial) of iron. I think that wastes 500 mg, and there is double-blind, prospective evidence supporting that conclusion. It costs $100 for an office visit, chair time nursing and IVs, which takes 15 minutes. If you visit twice, that’s an additional $100.The charges you mentioned suggest that an institution in New York is fleecing its clients or insurance companies. This is usury and should be investigated and stopped.
The health economist Richard Pollock is mistaken. IV iron is widely used in Great Britain and it is extremely likely, not unlikely, a patient with chronic blood loss would get IV iron, irrespective of symptoms. That being said, Ferinject, the European name for InjectaFer, costs $140 per gram and health providers don’t have to deal with the ridiculous 750 mg vial we do. Feraheme costs $466 for 510 mg and requires two vials for a gram (1,020 mg). Four insurers allow me to give 1,020 mg in a single 30-minute infusion: the Blues, MedStar, Priority Partners and Cigna. The rest, including Medicare and Medicaid, require two visits. The only benefit is to our practice, which gets $100 for the completely unnecessary second visit. Despite making it clear the single 1,020 mg infusion is just as safe and effective, you halve the number of IVs and chances for minor reactions. It’s not covered, I have no choice. A third get it once; two-thirds, twice. We charge $932 plus a 6% markup to cover nursing costs and paraphernalia.
INFeD, or low molecular weight iron dextran, costs $243 per gram, comes as 100 mg vials and requires 10 vials for 1 gram. It takes an hour and is just as safe and efficacious.
The author is mistaken about Venofer, iron sucrose and Ferrlecit, ferric gluconate. You can’t give more than 200-250 mg because the sugar that carries iron does so much less tightly than the carbohydrate cores of InjectaFer, Feraheme and INFeD. To give a gram takes four to five visits. I never use these drugs for that reason, but I have no criticism of nephrologists who use them in dialysis with thrice-weekly visits. Venofer is $600 per gram (definitely more than INFeD) and Ferrlecit $1,000 per gram.
The medical system you wrote is screwing the community. IV iron is an unmet need. Oral iron cannot keep up with losses in abnormal uterine bleeding, be absorbed after bariatric surgery, makes inflammatory bowel disease worse because it is directly toxic to the intestinal epithelium and makes the wrong bacteria grow, and most of all doesn’t get to babies in the third trimester when the fetal brain needs iron for normal development. IV iron is a godsend for millions.
— Dr. Michael Auerbach, Baltimore
Correct By Degrees
The article “‘Climate Grief’: Fears About The Planet’s Future Weigh On Americans’ Mental Health” (July 18) said a recent report by the Intergovernmental Panel on Climate Change predicts that “by 2040 the Earth will warm by 2.7 degrees Fahrenheit (1.5 degrees Celsius).” As the report’s opening page (to which you link) says, by 2040 the Earth will have warmed by 2.7F above preindustrial levels. That’s total warming over 200 years, not future warming in the next 22 years.
The report also provides little support for the extreme claims that have terrified so many people — and, even less excusably, terrified so many children. This is also true of many reports by the major climate agencies.
The IPCC is the largest and best-run project of its kind, ever — an assessment of current science, which is then summarized for non-scientists. The tragedy is that its work has been largely abandoned for propaganda that exaggerates or even ignores the findings. I believe this has caused the gridlock in U.S. climate policy, so that we are not only unprepared for future extreme weather, but for the inevitable repeat of past extreme weather.
— Larry Kummer, editor of the Fabius Maximus website, Davenport, Iowa
Editor’s note: Warm thanks for pointing out the error. Our article has been updated.
I mean, I'd refer to more as a crippling anxiety than "grief" but so long as there is a clinical term for it, sure: https://t.co/tphhE3J2R9
— Michelle Mills (@mlmills) July 18, 2019
— Michelle Mills, Chicago
For good reason, we are worried about climate change. But it's a slippery slope from saying we are distressed, to declaring being worried is a mental health disorder, to making a pseudoscientific mental disorder to proposing a treatment to cal not act. https://t.co/ySRVxxYaok
— James C.Coyne (@CoyneoftheRealm) July 21, 2019
— James C. Coyne, Philadelphia
Incrementally Exploited By Politicians
My copay requirement of $7,500 plus a monthly payment must be paid before my insurance pays any expenses. This is not health care. On paper I have health care; but the reality is I can’t afford to use it. It simply would stop me from bankruptcy in case of an emergency. However, these politicians and attorneys are making millions and getting a lot of publicity with every petition they file (“Biden’s ‘Incremental’ Health Plan Still Would Be A Heavy Lift,” July 22).
I feel the politicians should have the same health care choices as the American people. This would help them make better choices. Democrats and Republicans know health care in the U.S. is unaffordable. They should all be fired for not doing their job.
I also believe they should be able to serve only two terms, just like the presidential office. Politicians treat their position as a lifestyle instead of a job.
— Catherine Mossner, Gladwin, Mich.
The Battle For Uniform Excellence In Tribal Care
I’m part Inupiaq Eskimo from northwestern Arctic Alaska. The article “How The Eastern Cherokee Took Control Of Their Health Care”(July 22) states that the Cherokee benchmarked a program developed by Southcentral Foundation, a Tribal Health Organization originally created by an ANCSA (Alaska Native Claims Settlement Act) corporation but allowed to operate as a Public Law 93-638 entity. Awarded largely no-bid contracts through the Indian Health Service, Southcentral Foundation legally represents only shareholders of Cook Inlet Region Inc. — not all Alaska Native peoples.
To say SCF and other Alaska Natives run the program may be partly accurate, but it does not give credit to valuable contributors who served for decades ensuring we understood and implemented programs designed for all cultures — even families related to non-Indian Health Service beneficiaries.
Augusta Reimer is one of those deserving credit for this program. She was the first female Alaska Native/American Indian chief of an Indian Health Service department and was largely responsible for creating an atmosphere of wellness and creativity. Reimer, from IHS, and Mike McKeown from the University of Alaska-Anchorage designed my degree in human services; she spent hours working with interns and volunteers educating them on laws impacting us. Everyone who contributed deserves to be cited accurately and not just in a side note as other “Alaska Natives.”
The government has been pretty decent about encouraging native peoples’ self-determination, but it does not come without responsibility to follow the standards of care and communication and the law to ensure the quality and longevity of our programs.
The Indian Health Service was not approved to provide care to non-Indian health service beneficiaries. So the Nuka system of care — originally called Nutuqsiivik, which means “new beginnings” — was created to help identify gaps in data that were barriers to providing care to families with multiple health care providers and health and socioeconomic issues.
Indian Health Service programs have come a long way, but consistency and uniformity among tribal areas is highly concerning. In the age of a one-payer review, transparency is critically important. So is accuracy. Data and the lack thereof can cause a myriad of health and economic issues the patient or customer may have to deal with while their tribal organization isn’t monitored or corrected when needed. Without competition, I fear, these programs do not adequately respect patient needs, desires and have no real incentive to improve the quality of their care in order to keep their customers.
The Alaska legislature has created a committee specifically designed to educate lawmakers and the public on issues affecting the public and the tribes because there are so many of us. These programs do not live in a vacuum, but rather impact local economic development and regulatory control over your community. I encourage accountability among all parties and the mirroring of the U.S. Constitution and laws, so we have a legal template to follow.
— Cheryl Bowie, Anchorage, Alaska
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