Losing Out at the Casinos
Stephen Kamelgarn, MD, argues that “It’s Time for Casinos to Contribute,” in Editor’s Thoughts of The Bulletin of the Humboldt-Del Norte County Medical Society, August 2007.

“It is increasingly expensive to provide health benefits for one’s employees, and in today’s business climate of decreasing profit margins this can be the difference between making it and bankruptcy.

“However, there are businesses that do earn a significant amount of profit, and it is important for them to pick up their fair share of the load. Wal-Mart has been rightfully blasted in the national press for not providing benefits for their employees. This is a world-wide corporation that earns billions of dollars in profits every year. Yet, somehow, they can’t seem to get it together to provide benefits for employees who, in many cases, are earning just enough money to keep them for qualifying for Medicaid (Medi-Cal, here in California). Because of the national outcry Wal-Mart has begun to provide benefits for its employees.

“Locally, we’re seeing a similar situation with some local businesses. These are concerns that earn tremendous amounts of money, yet don’t provide for their employees. I am referring to the 3 local casinos (four, if you count the one in Klamath). In 2005, the Bear River Casino in Loleta grossed over $100 million, yet they provided no health insurance for many of their employees. If we assume that the other two casinos are doing as well as Bear River, then $300 million is going into their coffers.

“This is more than two thousand dollars per year for every man, woman and child in Humboldt County! It is not my point here to get into either the economics or morality of tribal gaming. But it is important to see that these casinos are tremendous cash generators, and a significant source of employment in the community, both for tribal members and non-tribal community members. Despite the fact that California State policy is that, in businesses of more than 50 employees, employers must provide insurance for anybody working more than halftime, the local casinos, being sovereign nations and therefore exempt from the rules, don’t provide for many of the employees who work much more than 20 hours per week. This is true, not only of Bear River, but also Cher-ae Heights, and Blue Lake casinos.

“I find this reprehensible. The fact that businesses can earn a quarter of a billion dollars in gross income, and not provide benefits for all of their employees bespeaks a level of callousness and greed that I find incomprehensible…”

The entire article can be read atwww.humboldt1.com/~medsoc/images/bulletins/AUGUST%202007%BULLETIN_for%20web.pdf

A New Vital Signs
Sandi Palumbo, the Executive Director for two medical societies, has announced a merger of their membership publications.

“With this month’s issue of Vital Signs, the Fresno-Madera Medical Society (FMMS) and the Kern County Medical Society (KCMS) are pleased to announce the merging of their respective membership publications, FMMS Vital Signsand KCMS Bulletin, into one combined enhanced monthly publication.

“This combined publication is yet another cooperative effort on the part of FMMS & KCMS designed to meet the needs of both organizations while decreasing the individual financial burden of such activity for both organizations. (Effective with my employment as Fresno-Madera Medical Society’s Executive Director early last year, through mutual agreement I also continued employment as Executive Director for Kern County Medical Society.)”

Incentivizing Prescriptions
David Aizuss, MD, warns “Beware These Prescribing Minefields” in the October issue of Southern California Physician, the publication of the Los Angeles County Medical Association.

“Health plans are now incentivizing their patients to convince their doctors to change medications.

“Physicians are under constant pressure to alter their prescribing habits – and new developments are adding to the force.

“In the past few years, there has been tremendous negative publicity about pharmaceutical manufacturers’ efforts to influence physician prescribing via ‘drug reps,’ or pharmaceutical detail salespeople. As a result, the Pharmaceutical Research and Manufacturers of America promulgated regulations that constrain what drug reps may do when they visit physicians’ offices. For example, the representatives must combine education with an offer of dinner or lunch. Further, the medical profession continues to debate the ethics surrounding pharmaceutical ‘freebies.’ I consider this a tempest in a teapot. What ethical physician would alter his prescribing practices based on pens and sticky notes?

“More recently, insurance companies are entering the game to alter physician prescribing habits. For example, earlier this year, as a patient, I received a letter from my insurance company suggesting that I ask my doctor to prescribe double the dose of my medication, so I could save money by cutting those pills in half with a pill cutter at home.

“I was incredulous – such a policy is clearly not in the patient’s best interest, but in the insurer’s best interest. It might reduce the co-pay for the patient, but it definitely reduces administrative overhead and processing costs for the insurer. Worse, the practice may even hurt patients. Among the obvious dangers are that patients cannot necessarily cut pills exactly in half, the distribution of medication and binder is unknown, the effect of gastric absorption cannot be quantified, and patients may become confused and cut the wrong pills.

“Another even less ethical practice was just brought to my attention. Some health plans are now offering physicians financial incentives to switch their patients from higher-cost to lower-cost drugs. One plan paid physicians to switch patients from Lipitor to a generic version of its competitor, Zocor. The physicians were paid $100 for each patient switched between Jan. 1 and March 31, 2007. Incentivizing physicians to switch a patient’s medication distorts the doctor-patient relationship and should not be permitted. The only consideration should be prescribing the best medication for the patient’s condition.

“If two medications have an equivalent effect on the patient, then it is reasonable to factor cost into the prescribing decision. However, in the example above, the patient was not a consideration. Cost alone was the deciding factor, and the incentive failed to consider patient needs.

“Finally, a colleague on the Los Angeles County Medical Association board recently showed me a letter that a health plan in California sent to its patients. It offered patients a free month of simvastatin if they convinced their physicians to switch them from Lipitor. Consequently, health plans are now incentivizing their patients to convince their doctors to change medications. This strikes me as wrong. It clearly undermines the doctor-patient relationship. We prescribe medications we think are best for patients, only to see them back in the office waving a coupon for a free month of medicine if we switch their prescriptions…”

The entire article can be found at www.socalphys.com/article/articles/581/1/Presidents-Letter—Beware-These-Prescribing-Minefields/Page1.html.