Some brief thoughts since I have to study for our end-of-clerkship exams.
1) I have observed ample revenue consciousness, but little cost consciousness, in my practice. A primary care practice is a small business and it won’t last long unless someone (or, several someones) is paying close attention to the bottom line. Practice revenue is highly scrutinized. However, I have never once heard the cost of a test or of an intervention discussed. Some of this is because the risk/benefit calculation for patients implicitly includes this calculation to some extent. And some of this calculation is probably made internally by the physicians without mentioning it to the patient. Some of this is because it is practically impossible to know the “true” cost of a test or drug – should we consider the out of pocket cost to the patient? the reimbursement rate of the insurer? the cost of the facility to run the test or to manufacture the drug? the sum total from all payers? And where are we to find this information if we wanted to employ it?
2) Having a primary care physician who will see you in the hospital is really cool. I think it is a big value add – especially when you consider the current difficulty of sending records from paper charts to the myriad hybrid paper-EMR systems that exist. Even if the chart were easily portable, it’s pretty hard to understand someone’s history from their (often incomplete or illegible) chart. That said, it’s not perfect, and fewer and fewer physicians are willing to do it, but if you can find one who is willing and who is otherwise a capable doc, I’d jump for him or her while you still can.
3) I am still not sure how I feel about in-office visits (lunches, etc) by pharmaceutical company reps. On the one hand, they provide free samples for your patients and free food for your hardworking office staff. Both of these things are valuable. However, the more you talk to these folks, the harder it is to ignore what they have to say. Especially because they are generally the most attractive, the most polite, and the all around nicest people in the room. They’re never pushy, and they’ll wait for hours without saying a word for your signature to confirm delivery of their samples. I think that I respect folks who make the decision to allow them in their offices, but that I don’t think I would follow suit.
For instance, last week a Takeda rep tried to convince me that edarbi (azilsartan medoxomil) is cheaper than generic losartan, based on an article from what was obviously a pharmaceutical industry front operation. I mean, I give the guy some credit for even trying since even the pharma reps admit this drug is a preposterously hard sell. But still, in the words of Ed Lover, “C’MON SON!!!” Losartan is about $50 at most pharmacies, while Edarbi is at least $80. Then again, captopril is on the $4 list …
One interesting counterargument, made by one of the docs in that practice, was that to even bring a seventh ARB to market shows that either Takeda is royally incompetent, or that they really believe they can steal market share and
FOOTNOTE: if you have never visited cafepharma.com, I HIGHLY recommend it. It’s an anonymous and semi-factual look into the wild world of pharma reps.
That’s all for now … I have tons of MKSAP questions to do (even though most of them are questionably relevant).