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Thursday, January 20, 2011

$52,000 for headaches: Multiple wrong-drug errors

In his fine essay in the New Yorker magazine this week, Dr. Atul Gawande described one woman as an example of a high-cost patient. She is a young migraine sufferer with diabetes, age 25. She had visited the E.R. about every ten days, i.e., 29 times, in a ten-month period, compiling bills of $52,000. She had faithfully filled her prescriptions, not missing a single renewal.

She'd take her medicine, but it wasn't working. When the headaches got bad, she'd go to the E.R. or to Urgent Care. The doctors would order CT scans and MRIs to ensure she didn't have a brain tumor or aneurysm (a blood-filled balloon-like bulge in a blood vessel), give her a narcotic injection to temporarily stop the headache, renew her prescription for imipramine if needed, and send her home. The next time she had a migraine, she'd go to the E.R. again and see the doctor then on duty, repeating the pattern. She wasn't having a primary care physician try different medications systematically to figure out how to prevent or limit her migraines.

She is an employee of a company that pays for her health care. At that company, like most, a very small fraction of patients consume a very disproportionate share of all healthcare expenses. The E.R. is the wrong place to treat people with a chronic condition like hers.

Three kinds of people could help her escape this agonizing pattern: medical providers, her employer, and she herself. First, the E.R. doctors might well have recognized her as one of their "frequent flyers." It's a shame none of them helped her get a primary care provider. (That would have gotten her better care, reducing costs by cutting the hospital’s E.R. revenue.) Second, the employer might have recognized that her medical care was poor. Indeed, the employer had hired Verisk Health to analyze their costliest patients' care, and Verisk’s research director discovered the problem in the woman’s pattern of care. It's not clear from Gawande's essay whether the unfortunate woman eventually received better care as a result of the data analysis. Third, the woman herself, or a friend, family member, or other patient advocate might have realized that her medical care was poor. Lacking that, the woman apparently took for granted that suffering in this way was her lot in life. She didn't think to advocate for herself.

Advice: If you're limited by poor health, ask an advocate if anything can be done to make your life easier.

Read another story on migraines. Thanks to Dr. Atul Gawande for the source essay in the New Yorker of January 24.

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