Consumer-Driven Health Care: The Changing Role of the Patient

Posted on by

The latest trend in health care? Patients are managing their own care. New technologies make it possible. Legislative changes facilitate it. And financial pressures all but require it. Today, for example, patients can:

  • Use the Internet to freely browse medical journals and libraries for information previously available only to professionals at a cost of thousands of dollars.
  • Test children for ear or strep infections at home. Using over-the-counter do-it-yourself diagnostic kits saves unnecessary trips to the doctor.
  • Obtain a battery of more than 50 blood tests for as little as $90 by leaving a blood sample at a commercial testing center.
  • E-mail personal physicians to obtain a diagnosis, rather than making an in-office visit.
  • Use the Internet to have test results evaluated or obtain a second opinion from a Web-based physician.
  • Shop online for lower-cost prescription drugs or over-the-counter equivalents, saving up to 90 percent off the cost of brand name prescriptions.

Nearly half of Americans (45 percent) have some type of chronic condition. Patients with chronic diseases can manage their conditions and control their health care in ways unheard of only a few decades ago. For example, patients with diabetes can be trained to inject insulin, monitor and maintain a log of blood glucose levels, and use the results to adjust their dietary intake, activity levels and medicine doses.

Patients who manage their own care obtain results as good or better than those with standard physician care and can substantially lower health care costs in the process:

  • Asthmatics can use a software package to monitor their condition and transmit the data over the Internet to a physician for evaluation.
  • Patients with hypertension can test themselves and adjust their medications, based on a formula approved by their doctor.

Patients also have new financial incentives to manage their own care. Employers almost everywhere are raising deductibles and increasing copayments — forcing employees to manage more of their own health care dollars whether they want to or not. Health Savings Accounts (HSAs) are additional incentives that let employees (or their employers) deposit tax-free dollars into an account for current or future health care needs. HSAs are now available in principle to 250 million nonelderly Americans. As a result, the number of people with personal health accounts is expected to grow from about one percent of workers (1.5 million) in 2002 to more than 18 million by 2012.

There are legal and regulatory barriers to the fuller development of patient self-management. For instance, many state medical boards find the practice of cyber-medicine unethical if a consultation does not involve face-to-face examinations. Thus, consulting a physician online or getting a second opinion by way of the Internet (especially across state borders) is often difficult — if not illegal.

State and federal laws keep practitioners from paying nominal fees to organizations that schedule patient appointments or refer patients to them. This prevents the emergence of Internet-based medical service brokers similar to Web sites that sell airlines tickets online. It also makes it difficult to create medical auction Web sites (similar to eBay or Yahoo) where physicians compete on price and services.

Consumers also need greater access to drugs therapies over the counter. Unfortunately, the Food and Drug Administration’s (FDA) recent track record of moving medications to the OTC market is decidedly mixed. Over the last two decades, for every drug switched from prescription-only to over-the-counter in the United States, Europeans have switched more than four. This includes Simvastatin, a popular cholesterol reducer, which is available over the counter in Britain (after a short pharmacist consultation) under the brand name Zocor Heart Pro.

If the obstacles to consumer driven health care were removed, health care quality would improve, and rising costs would be better contained.

[page]

Figure I - Paying Directly for Medical Care

Consumer driven health care is a new paradigm for health care delivery. Defined narrowly, consumer driven health care refers to health plans in which individuals have a personal health account, such as a health savings account (HSA) or a health reimbursement arrangement (HRA), from which they pay medical expenses directly. The phrase is sometimes used more broadly to refer to defined contribution health plans, which allow employees to choose among various plans, often with a fixed dollar contribution from an employer. Those who opt for plans with rich benefits may have to contribute a significant amount of their own money in addition to an employer’s contribution. Those with more basic coverage contribute less of their own money.

“People with personal health accounts have economic incentives to better manage their own care.”

More choice and greater control over one’s health plan are characteristics of a consumer-driven health care market place.1 People with personal health accounts have economic incentives to better manage their own care. The reason: In addition to health benefits, they realize economic rewards for making good decisions and bear economic penalties for making bad ones. These economic incentives make patients more likely to seek information about medical conditions and treatment options, including information about prices and quality. Patients will respond to these incentives in different ways. Some will seek information about diseases, treatments and health care providers over the Internet, including comparative information about treatment outcomes of individual health care providers and the fees they charge. Some may bypass primary care physicians and directly order their own diagnostic tests or seek online consultations. Others may bypass brand name drugs and obtain less expensive generic substitutes, therapeutic substitutes and over-the-counter drugs. In general, people will consume fewer medical services, and pay less for health care in the long run when they are spending their own money.2

Figure II - Federal and State Tax Subsidies for Health Insurance

By contrast, most patients have few incentives to be prudent consumers of medical services in the current health care system. The reason: Third parties — government, employers or insurance companies — pay for about 86 percent of all health care.3 As a result, the economic incentive for patients is to consume medical services until they are worth only 14 cents on the dollar. [See Figure I.]

“Third parties pay for about 86 percent of all health care.”

Excessive physician visits is one way in which patients waste health care dollars. Up to one-quarter of physician visits are for conditions patients could easily have treated themselves, according to employee benefits experts.4 A recent report by the Agency for Healthcare Research and Quality even suggests that an annual physical is of little value.5 Patients also waste money through nonemergency visits to hospital emergency room. Even though these are one of the most costly ways to obtain routine treatment, 55 percent of the 103 million visits to hospital emergency rooms are judged unnecessary. Overall, the total cost of unnecessary physician office visits and unnecessary emergency department visits is just under $31 billion annually, or about $300 per American household per year.6

If third-party payment for medical bills is so wasteful, why do Americans rely on it so heavily? The main reason is tax law. Employer payment of health insurance premiums is excluded from the taxable income of employees, a subsidy worth up to 45 cents on the dollar for many workers.7 Yet, until recently, employer deposits to an employee owned and managed health savings account (HSA) were fully taxed — meaning government took almost half the deposit for the middle-income workers. Thus, the tax law generously subsidized third-party payment of medical bills but penalized deposits to accounts used to purchase care directly. As a result of legislation that became effective in 2004, these perverse incentives are finally changing. [See Figure II.] [page]

Whether they like it or not, patients are likely to manage more of their own care in the future. This is the result of several trends.

Patients Can Access More Medical Information. With the advent of the Internet and the ease of access to medical information, patients no longer have to rely on physicians to answer every question. They can obtain medical information directly. The growth of the Internet and the vast amount of information it makes available are leading to dramatic changes in information delivery.8 About 80 percent of adult Internet users (estimated at 93 million people) have searched for health information online.9 Estimates vary, but by most accounts there are approximately 20,000 health-related Web sites.10 These activities constitute a sharp break with the tradition of doctors as the sole source of health related information. In the past, much of the medical literature was available only at large libraries, medical schools or by subscription to expensive scholarly medical journals. Now, much of this literature is readily available to anyone with Internet access.11

According to a recent survey of patients visiting an internal medicine practice, more than half (54 percent) had used the Internet to gather health information. Of these, about six-in-ten (59 percent) rated the information “the same as” or “better than” information they got from their doctors. An equal number (60 percent) did not discuss the findings with their physician.12

Another way patients find out about medicine is direct-to-consumer advertising, which is mostly about drug therapies. Drug advertising benefits patients because it educates them about new treatments and often prompts them to seek care for previously untreated medical problems.13 In 2000, drug manufacturers spent $2.5 billion on direct-to-consumer advertising; about $1.5 billion dollars was spent to promote a mere 20 drugs.14

“Federal tax law subsidizes third-party payments.”

There Are More Treatment Options. Medical science has made enormous advances in the past few decades, increasing the range of therapies available to patients. Prescription drug therapy is an area where consumers have the most choices. For example, U.S. companies developed 370 new medicines within the last decade alone, according to the Pharmaceutical Research and Manufacturers of America.15

Take heart disease, for example.16 Most experts suggest patients reduce the risks of heart disease using behavior modification involving diet and exercise.17 Patients with high cholesterol may select from any number of cholesterol-reducing drugs from a class known as “statins.” Patients with hypertension can use beta-blockers, calcium channel blockers and angiotensin-converting enzyme (ACE) inhibitors to lower blood pressure.

When patients develop heart disease they often can choose between invasive surgery or various drug treatments. For instance, heart disease may be treated with surgery, such as angioplasty with stents to open clogged arteries or coronary bypass grafts where arteries are too clogged to reopen. Drug treatments include virtually all of the same drugs use to prevent heart conditions. In addition, most cardiac patients are prescribed diuretics and a small daily dose of aspirin to reduce the risk of heart attack.18

“Having more choices, patients want to make more decisions.”

Having more choices available, patients increasingly want to participate in decisions about which treatments they receive.

Doctors Can’t Manage Patients’ Care. In the past, many patients had a “personal” physician who met most of their health needs. In addition to examinations and treatments, doctors also were responsible for patient education.19 The ongoing relationship between the physician and patient was an information exchange, in which patients told their doctors about their symptoms and doctors provided diagnoses and recommended treatments.20 This trusting relationship has changed for a number of reasons. Among them: 1) Increasing medical specialization means that no single physician can provide all the information patients need, and 2) Physicians do not have enough time to give their patients complete information on their health. As medical knowledge has grown, an increasing proportion of doctors have specialized so that no individual physician can provide all the care a patient may need. Even within their specialties, doctors have trouble staying current in their field. About 10,000 clinical studies occur every year, and by some accounts, medical knowledge doubles every 42 months.21

“More than three-fourths of patients think medical errors could be reduced if physicians spent more time with patients.”

All specialty boards in the American Board of Medical Specialties require their members to take periodic exams to maintain their certification but most experts admit it is not enough to keep physicians current in their field. Many older doctors are exempt from periodic testing and don’t stay current.22 There is also a problem in the allocation of the physician’s time. A recent study in the American Journal of Public Health estimates that physicians would spend seven hours a day providing preventive care counseling to patients if they followed all of the recommendations of the U.S. Preventive Services Task Force.23 Although the average time physicians spend with individual patients has not fallen significantly, because of the increasing amount of information to be conveyed, and preventive and treatment measures to discuss, the proportion of physicians saying they do not have enough time to spend with patients rose nearly 24 percent between 1997 and 2001, from 28 percent to 34 percent of doctors surveyed.24 Patients are less likely to trust a diagnosis made by a specialist who spends only a few minutes with them.25 According to a recent article in the Journal of the American Medical Association, patients usually want more information about their medical condition than they receive from their doctors. For instance, during a 20-minute office visit physicians spend less than one minute discussing planning and treatment, on the average. Doctors discuss options and help patients arrive at a treatment based on their preferences during fewer than one in 10 office visits. About half the time, doctors fail to ask patients if they have questions.26

Figure III - Preventable Medical Errors

“Physicians spend less than one minute per office visit, on average, discussing planning and treatment.”

A Harris Poll found that even when physicians offer to answer patients’ questions, 60 percent of patients forget some of the questions they mean to ask.27 Moreover, patients retain only a fraction of the information they receive from their physician during an office visit.28 People think this lack of communication affects the quality of patient care. For instance, more than two-thirds of the public (72 percent) thinks “insufficient time spent by doctors with patients” is one cause of preventable medical errors, and three-fourths (78 percent) think that the occurrence of medical errors could be reduced if physicians spent more time with patients.29 [See Figure III.]

Physicians will always serve an important role advising patients about their medical needs. But patients need other options. Patients seeking medical information on their own are partially substituting for the service of physicians.30 A few hours spent on the Internet may substitute for a costly face-to-face office visit.

Managed Care Created Distrust of Insurers. In the 1980s and 1990s, employers began replacing fee-for-service health plans with managed care in an attempt to reduce their health care costs. Managed care organizations tried to hold costs down by negotiating deeply discounted fees with providers and by limiting access to services they deemed unnecessary. They often limited doctor discretion and replaced it with protocols for managing patient care. In many cases physicians were directly employed by health insurers and given financial incentives to withhold or limit access to types of care the insurance companies considered wasteful or costly.31 Even today, nearly one-third (31 percent) of U.S. physicians report they sometimes do not discuss useful treatments that are not covered by insurers.32

Practices like these led to a consumer backlash in the 1990s, as patients saw managed care as a threat to their health and well-being.33

“The number of people with health savings accounts could grow to 18 million by 2012.”

Employers Are Requiring Workers to Share More Costs. Employers are increasingly shifting health care costs and risks to employees.34 For instance, during the period from 1993 to 2004, the average annual deductible workers with conventional health plans had to pay before insurance began to pay rose an average of 86 percent from $222 to $414. For family plans, the deductibles rose by 74 percent ($495 to $861).35 Over the past 10 years PPOs with higher deductibles have been replacing first-dollar HMO plans.36 PPO coverage has risen from 27 percent of all covered employees to 58 percent. PPO plans have higher deductibles and 31 percent of PPOs used by small employers now feature in-network deductibles of $1,000 or more.37

More employers are offering consumer-driven health plans, which usually include high deductible health insurance coupled with personal health accounts which workers use to pay for their incidental medical spending.38 A recent Milliman employer survey found that almost all (98 percent) employers are considering offering high deductible health plans, whereas in 2003 less than half (48 percent) considered offering them.39 In 2002, only about one percent of workers (1.5 million people) had health plans featuring personal health accounts.40 According to a new estimate by Forrester Research, the number of people with health savings accounts could grow to 18 million, with $35 billion in assets, by 2012.41 [See the sidebar “Personal Health Accounts.”]

Personal Health Accounts

Health Savings Accounts (HSAs).42 As of January 1, 2004, 250 million nonelderly Americans, at least in principle, have access to HSAs, provided they are combined with catastrophic insurance coverage. HSAs allow individuals and employers to make annual deposits up to the health insurance deductible. The health insurance policy accompanying an HSA must have an overall deductible of at least $1,000 for an individual or $2,000 for a family policy. A typical plan works like this: When individuals enter the medical marketplace, they spend first from their HSA. If they exhaust their HSA funds before reaching the deductible, they then pay out-of-pocket. Once they reach their deductible, insurance pays all remaining costs.

Annual HSA tax-free deposits typically cannot exceed $2,650 for individuals and $5,250 for families.43 The account balances can be invested in stocks and bonds and other financial assets, and they grow tax free. Thus a young person could accumulate hundreds of thousands of dollars by the time he or she retires.44

HSA balances belong to the individual account holders and remain theirs if they switch jobs, become unemployed or retire. The funds can be used to pay expenses not covered by insurance, insurance premiums while unemployed and health expenses during retirement. In the event of death, HSAs may be bequeathed to a spouse, or (like an IRA) the funds may flow to other heirs.

Flexible Spending Accounts (FSAs).45 Flexible spending accounts allow employees to set aside money tax-free for anticipated medical needs. FSAs are strong in areas where HSAs are weak — and vice versa. Though FSAs have no insurance requirement and no funding limits, they may be used only for medical expenses. Moreover, employees forfeit any funds left in the FSA at year’s end or when they leave their job. This use-it-or-lose-it rule encourages workers to spend in wasteful ways. FSAs would be more attractive to workers (and would come closer to leveling the playing field) if they were made portable from year to year, and from job to job.

Health Reimbursement Arrangements (HRAs). A June 2003 IRS Revenue Ruling clarified that HRAs funds could be rolled over tax free. They are similar to FSAs, with important exceptions. Unlike FSAs, only employers may contribute to HRAs. At an employer’s discretion, workers may roll over unspent HRA balances from year to year and may have access to leftover balances after they leave a job. Although HRAs are more flexible than FSAs, in the long run they too are governed by a use-it-orlose- it rule. The funds can be spent only on health care or insurance premiums and can never be withdrawn as cash.

[page]

Figure IV - Patients Exchanging E-mail with Doctor

Americans have a powerful new tool with which to educate themselves and manage their own health care needs: the World Wide Web.46 The Internet is a portal to medical libraries and Web sites with disease-specific information, and it gives patients direct access to prescription drugs, direct laboratory testing services, and therapeutic alternatives.

“Two-thirds of people who seek health information on the Internet search for data on specific diseases.”

Obtaining Information on Conditions and Treatments. The Internet allows access to medical information that was unavailable to ordinary Americans only a decade ago. And people are responding. In 1997 the National Library of Medicine eliminated fees to search its “MedlinePlus” Web site, the world’s largest medical library,47 and the number of searches rose from about seven million a year to 180 million — about 60 million of which were by the general public rather than medical professionals.48 The American College of Physicians Foundation encourages doctors to send patients to MedlinePlus,49 a practice referred to as writing prescriptions for “information therapy.”50 Although physicians have been slow to embrace the trend, patients who obtain information from the Internet potentially save physicians time when they arrive for an office visits more fully informed.51

Two-thirds of people who seek health information on the Internet search for information on specific diseases. A survey indicates the information sources they are using.52

  • Most people (83 percent) search for medical studies
  • Seventy-one percent go to the Web sites of medical societies.
  • About 39 percent go to the Web site of nonprofit organizations, such as patient advocacy organizations and disease research groups.
  • Thirty-eight percent search Web sites for information about clinical trials for new therapies.
  • Almost one-third (32 percent) go to commercial health Web sites, such as product-specific sites maintained by drug companies.

Figure V - Sales of Over-the-Counter Diagnostic Tests

Obtaining Advice from Physicians. Most patients with Internet access (90 percent) would like the ability to consult their physician by e-mail, according to a Harris Interactive poll.53 However, only a few doctors offer patients the ability to request services or prescriptions by e-mail.54 According to a 2001 survey, only about 14 percent of patients exchange e-mail with their physicians and only a tenth of these do so on a frequent basis.55 [See Figure IV.]

“About 14 percent of patients exchange e-mail with their physicians.”

One obstacle to e-mail consultations is that few insurance companies will reimburse physicians for this service.56 Some health plans will not compensate doctors for e-mail exchanges unless the patient has first been examined in an office.57 Other insurers reimburse less for e-mail exchanges than for in-person visits.58 However, this is changing. For example, Blue Shield of California pays physicians the same for an e-mail consultation ($25) as it does for an office visit.59 Furthermore, in January 2004, the American Medical Association created a reimbursement code for online consultation patients, making it easier for physicians to get paid.60

Physicians who exchange e-mail with their patients find it often replaces telephone consultations. But patients who send e-mail messages tend to spend more time composing their thoughts and create more focused messages than they do for phone conversations.61 An example of this new paradigm is Alan Dappen, M.D., who practices medicine almost entirely by telephone and e-mail contact. His time is billed in 5-minute increments and ranges from $25 for in-office visits to $15 phone consultations with patients who have set up prepaid accounts.62

Figure VI - Drugs Used by Americans

Obtaining Diagnoses. Patients have access to an increasing number of medical tests to assess the state of their health and diagnose their ailments. They can now order a variety of tests directly that were once exclusively available only at a physician’s request. But they often have to pay for these tests of pocket. Many tests are offered by pharmacies and other retailers over the counter.63 Sales of self-diagnostic over-the-counter tests64 tripled from $750 million in 1992 to $2.8 billion in 2002.65 [See Figure V.]

Home pregnancy-testing kits have been available for years. In fact, they have become so ubiquitous that they are sold in grocery stores everywhere. In some cases, they can be purchased at inexpensive “dollar stores” for $1 a piece.66 High quality pregnancy test strips are available in bulk on eBay.com for 50 cents apiece. Pregnancy tests were followed on to retail store shelves by ovulation predictor tests.

“Sales of self-diagnostic over-the-counter tests more than tripled from $750 million in 1992 to $2.8 billion in 2002.”

Do-it-yourself tests are proliferating, making self-diagnosis easier than ever before.67 These include tests for HIV, prothrombin time (clotting) for bleeding disorders and hepatitis C infections.68 For example, ear infections are the number one reason children see a doctor — accounting for 20 million office visits annually.69 The EarCheck Middle Ear Monitor is a home testing device for inner ear infections that uses sonar to check behind the eardrum for fluids that may indicate ear infection.70 The monitor costs about $50, an amount roughly equal to the fee for a single office visit. Likewise, children often get sore throats —which usually don’t require a physician visit. Families can buy a QuickVue Strep Test, which costs $90 for 25 tests. Each test helps differentiate strep infections (that require a physician visit) from viral infections (that do not require physician care). The test is simple to use — swab the back of the throat with the applicator, then add a reagent. The color change determines the diagnosis.71

The FDA recently approved a Menopause Home Test as the newest entrant into the field of OTC home diagnostics. The kit contains two pads for measuring the serum FSH level (which indicates the onset of menopause). The test is designed to make women aware of the possible onset of menopause without the inconvenience and cost of a physician visit. (Some physicians question the benefit of this test, mostly because they don’t understand how much patients value this knowledge.72)

“Patients can order a blood work up for about $95.”

Numerous tests can now be done on blood, and many of these are readily available to patients without a doctor’s prescription. Another option that may soon be available to patients is screening storefronts or kiosks that offer lab tests in a convenient setting and provide results quickly, without consulting a physician. The results of a typical physician-ordered blood test are delayed at least a day when they are sent out to a lab. Follow up consultations and/or playing “phone tag” can add more time. However, a Culver City, California-based company (Careside, Inc.) sells a much smaller blood testing machine that can provide results for the 36-most commonly-ordered blood chemistry tests in about 15 minutes.73 It costs about $10,000, a fraction of the price of most laboratory testing machines, making it affordable for testing centers or individual physician practices.

Figure VII - Prescription Drugs Switched to Over-the-Counter

“Over-the-counter drug products account for 60 percent of drugs used by Americans.”

One firm, Quest Diagnostics, has aggressively moved into the field of patient-ordered medical testing.74 The Web site QuesTest.com features a health library that patients can use to learn more about the tests Quest offers. Another medical testing laboratory, HS Labs (BloodWorksUSA.com), allows patients to pay a fee online, then stop by one of a nationwide network of collection points where a lab technician can draw a blood sample. HS Labs offers a complete blood work special for about $95 that examines numerous metrics.75

A competing laboratory service, Direct Laboratory Services, Inc. (DirectLabs.com), offers a similar battery of tests priced at $89.76 This blood profile provides a thorough biochemical assessment of health based on more than 50 individual tests including blood count, thyroid profile, lipid profile, liver profile, kidney panel, profile of minerals and bone, fluids and electrolytes and tests on diabetes. The company works with more than 5,000 labs so the service is available in most parts of the country.

“Patients can order genetic tests to determine their risk for cancer or heart disease and diagnostic imaging to discover if disease is present.”

Patients can also order genetic tests to determine their risk for cancer or heart disease and diagnostic imaging to discover if disease is present. Prices for patient-ordered genetic testing for susceptibility to breast and ovarian cancer range from $586 for a single point mutation to $3,312 for a complete sequence.77 Patients can also order “virtual exams” using MRI or PET technologies to detect cancer, heart disease and other conditions.78 Many physician groups oppose the use of patient-ordered body scans in asymptomatic patients because these often yield ambiguous results that require patients to spend money on follow-up tests.79 However, medical societies support doctor-ordered preventive screening tests for various conditions at ages called for in medical protocols. Patients who are aware of the recommended screenings can order many of those tests themselves, for less than a doctor would charge. The difference: Patients typically have to pay for scans they seek out themselves out of pocket, whereas doctor-ordered tests are more likely to be reimbursed by insurers.80

Self-Treatment. According to an article in the British Medical Journal, only one out of every 40 symptoms results in a patient making an office visit for a medical consultation.81 For example, it has been estimated that, at some point in their lives, between 15 percent and 40 percent of the general population experiences gastrointestinal symptoms such as rectal bleeding, irritable bowel syndrome, and dyspepsia (chronic indigestion). Yet only a quarter to a third of people experiencing these symptoms ever consults a practitioner.82 The information they obtain on the Internet often allows patients to make their own decisions about which symptoms require consultations.83

For most medical conditions, people initially self diagnose and treat symptoms, usually with OTC drug remedies. OTC drug products account for 60 percent of drugs used by Americans.84 [See Figure VI.] Estimates vary, but according to Rottenberg, Americans buy OTC drugs about 12 billion times a year. If only two percent of them sought professional care, rather than treating themselves, the increase in office calls would require 50 percent more primary care physicians than are currently available. If everyone using OTC drugs sought the advice of a physician, the number of primary care physicians needed would be 25 times greater than the number we currently have.85

Table I - Case Study%3A Cardiovascular Medications

“Eighty-nine prescription drugs, including specific strength doses of some drugs, have been switched to over-the-counter since 1975.”

Eighty-nine prescription drugs, including specific-strength doses of some drugs, have been switched to over-the-counter since 1975.86 Millions of Americans use these drugs. For example, first generation antihistamines are a popular class of drugs sold over the counter with 14 different formulations available since 1975.87 It is estimated that 20 million allergy suffers were self-treating with OTC (sedating) antihistamines in 2002, almost half of the total number of Americans suffering from allergies.88 Claritin, a second-generation antihistamine, one of the best-selling allergy medications, was moved to the OTC market in December 2002.89 Claritin is an improvement over earlier allergy drugs due to its nonsedating characteristics. The 20 million that were treating themselves with other OTC remedies (and the millions whose symptoms go untreated) are candidates for Claritin or its generic equivalent Loratadine.90 Virtually all patients on a second-generation prescription antihistamine are candidates for OTC Claritin. Prescription antihistamines generated about $4.7 billion in sales in 2002.91

“A patient with a prescription can find a range of prices by clicking on a few Internet pharmacy Web sites.”

Another example of a popular prescription drug recently moved to the OTC market is the antiulcer drug Prilosec — which was the second best-selling drug in 2001.92 When it became available over the counter in the fall of 2003, it sold for around 70 cents per capsule compared to almost $4 for the prescription version. Access to popular prescription drugs, such as Claritin and Prilosec, make it both easier and cheaper for consumers to obtain treatment. Not only are these two drugs top sellers, they are both from classes of drugs that have been among the most widely sold. Patients taking any of the other prescriptions drugs in their respective classes might be able to switch to the OTC version of Prilosec or Claritin and save a bundle. [See Figure VII.]

Giving consumers access to medical technology also helps patients since doctors may not be readily available when patients need them. For instance, about 70 percent of heart attacks occur in the home. Philips Electronics now offers a FDA-approved defibrillator for home use that does not require a doctor’s prescription.93 For less than two thousand dollars, consumers can be prepared to treat a cardiac emergency themselves.94 (See the discussion below on Monitoring and Treating Chronic Conditions.)

“Seniors can reduce the cost of some common drug therapies by more than 90 percent with the same techniques they use when shopping for other goods and services.”

Shopping. Consumers have never had more opportunities to obtain price information about drugs. A patient with a prescription can find a range of prices by clicking on a few Internet pharmacy Web sites. The Internet makes it easy to look up information on government and private programs to assist elderly, low-income and disabled patients. Additionally, Web-based services help patients find comparable medications that are cheaper than their current prescriptions. Patients can cut costs substantially by becoming aggressive consumers. In fact, seniors can reduce the cost of some common drug therapies by more than 90 percent if they use the same buying techniques they routinely use when shopping for other goods and services.95

Case Study: Cardiovascular Drugs. Patients prescribed 50mg of Tenormin daily can save money by comparison shopping for the best price and quantity. [See Table I.] For instance:

  • Our survey found that the price of 100 (50mg) doses of Tenormin ranged from $149.93 at Drugstore.com to $130.49 RxUSA.com.
  • But patients could save at least 75 percent over the lowest cost brand-name drug by switching to the generic alternative Atenolol.
  • One hundred doses of the generic drug ranged $21.67 at RxUSA.com to $7.99 at Costco.com.
  • Finally, consumers could save another 45 percent (from $12.50 to $6.87) by buying larger pills (100mg) and splitting them in half.

Smart buying of this drug lowered the potential overall cost by 95 percent — from a high of $149.93 to a low of $6.87.

[page]

Treatment of chronic diseases is one of the factors driving up health care costs. Nearly half (45 percent) of all Americans have a chronic condition, and half of those (60 million) have multiple chronic conditions.96 A Yale University study found that one-quarter of Americans have one or more of five chronic conditions: mood disorders, diabetes, heart disease, high blood pressure and asthma. Moreover, patients with these conditions account for almost half of all health care spending.97

“Nearly 45 percent of all Americans have a chronic condition, and half of those (60 million) have multiple chronic conditions.”

Patients with chronic illnesses can use the Internet to obtain information on specific medical conditions, clinical trials and the latest drugs. They can also share their experiences with and learn from others suffering from the same conditions. Once patients inform themselves, they can manage their conditions and control their health care in ways unheard of only a few decades ago. Following are some examples of how patients with some common chronic conditions can take a more active role in their own care.

Heart Disease . Heart disease, the most common chronic condition, is America’s number one killer. According to the American Heart Association, 65 million Americans have high blood pressure, resulting in 5.4 million strokes per year.98 In 2005, hypertension will cost nearly $60 billion ($59.7 billion). The cost of strokes, which are frequently a complication of hypertension, costs an additional $56.8 billion. The average cost, in present value dollars, of treating cardiovascular disease for the duration of life for the average 45-year old is $30,000.99

Patients with high blood pressure have opportunities to reduce their cost of treatment by shopping. For example, those on the anti-hypertensive drug Cardura (Doxazosin) can split double-strength tablets for a savings of 46 percent.100 In addition, research has found that an inexpensive “water pill” (diuretic) is more effective than many newer, higher-priced antihypertensive medications such as ACE inhibitors and calcium channel blockers.101 For this reason, experts say low-cost diuretics should be a hypertensive patient’s first step in controlling high blood pressure.102

“Some 65 million Americans have high blood pressure, resulting in 5.4 million strokes per year.”

In addition to shopping, patients with hypertension can take a more active role by administering their own tests. A controlled study of more than 300 patients with high blood pressure found that patients who monitored their own blood pressure and adjusted their own medications had 27 percent fewer physician office visits than those who did not.103 Those who self-medicated were given a $40 blood pressure monitoring device and a formula to adjust their medication. They achieved blood pressure control similar to those who depended on a physician to adjust their medication.

There are also cheaper medication options many hypertensive patients can use to reduce the risk of stroke, a major complication of hypertension. A recent study in the Journal of the American Medical Association found two daily aspirins were as effective at preventing recurrent strokes in African Americans as a daily 500mg dose of the drug Ticlopidine.104 This is a significant finding, given the fact that Ticlopidine can easily cost patients almost $65 per month.105

“Nearly $2.5 billion in annual hospital costs for diabetes complications could be averted with appropriate care.”

Diabetes. More than 16 million Americans have diabetes — the sixth-leading cause of death by disease in the United States.106 The mortality rate for people with diabetes is 11 times the rate for those without the disease.107 In addition, diabetics spend four times more money on health care than nondiabetics.108 There is much to be gained from better disease management. By one estimate, nearly $2.5 billion in annual hospital costs for diabetes complications could be averted with appropriate care.109 Numerous studies have shown considerable benefit from self-management training for Type 2 diabetes.110 Patients can be trained to inject insulin, monitor and maintain a log of blood glucose levels, and use the results to adjust their dietary intake, activity levels and medicine doses.111

There are approximately 20 different monitors to test blood glucose available in a variety of shapes and sizes.112 Occasionally monitors are given away free — but some only work with a proprietary brand of glucose test strips and therefore are more costly in the long run.113 Costs for test strips vary considerably. A diabetic patient could pay $69.99 for 100 Ascensia Microfill Blood Glucose Test Strips at Devine Medical’s Web site.114 However, the same 100 count box is sold on eBay for $59.95.115 If patients who check their blood sugar four times a day could save 25 cents per test strip, the savings would add up to $365 for the year.

In the past few years several new oral medications for diabetes became available.116 Savvy consumers will also find the price of diabetic medications vary considerably.117 Some are available in generic form while some are not. In addition, many diabetics can reduce reliance on medications and control their diabetes completely by adhering to a meal plan, losing weight and exercising.118

Asthma Self-Management. From four to six percent of the population of Western countries has been diagnosed with asthma. Uncontrolled asthma imposes economic costs on society.119 The Asthma and Allergy Foundations of America estimates nearly 20 million Americans suffer from asthma — resulting in 500,000 hospital stays each year.120 More than 2.5 million school-age children suffer from asthma, missing nearly 15 million school days per year. The economic loss averages out to nearly $800 per child per year.121 A Dutch study comparing self-management to usual care found that those monitoring their own asthma achieved a savings of about 7 percent the first year and a 28 percent savings the second year compared to those in standard care with a primary physician.122

Patients should develop a self-management plan with their physician or asthma nurse. An asthma plan is essentially a list of established guidelines indicating which actions to take in response to various symptoms.123

Asthmatics can use a software package called Asthma Assistant to monitor their condition.124 This computer program helps patients measure their condition on a daily basis, including peak air flow, medication and events that may trigger symptoms. Such biometric data can be transmitted over the Internet from a patient’s computer to a physician’s office computer for evaluation by a doctor or technician (a process called telemonitoring). The software program analyzes airway obstruction data gathered by the patient using a spirometer, which measures the speed and volume of exhalations. A recent study of asthma patients trained to perform in-home asthma telemonitoring found that the results of self-testing were consistent and met established guidelines. Moreover, participation in telemonitoring did not require that patients have extensive computer knowledge.125 Some 87 percent of patients in the study were “strongly interested” in continuing to use this method.

Bleeding and Clotting Disorders . A variety of conditions cause patients to bleed too freely or their blood to clot too readily. A study of Veteran’s Administration patients found that home self-monitoring of prothrombin time (clotting) while taking Coumadin (Warfarin) to reduce the formation of blood clots is superior to standard monitoring by physicians. The “bleeding rate” was 11 percent for patients monitored monthly at a clinic, but only 4.5 percent for patients who monitored their own prothrombin time at home on a weekly basis. The rate of blockages caused by blood clots, known as thromboembolism, was four times higher with standard follow-up therapy than with self-monitoring (3.6 percent each year versus 0.9 percent). Serious cases of bleeding (and/or thromboembolic events) occurred in 2.7 percent of cases per year in the standard-monitoring group but there were none in the home-monitoring group.126

“Self-monitoring saved asthma patients about 7 percent the first year and 28 percent the second year compared to physician monitoring.”

Migraine Headaches . The National Headache Foundation estimates that 28 million Americans suffer from migraine headaches each year, resulting in the loss of 157 million workdays.127 The cost of migraine headaches on the economy is estimated in the billions of dollars.128 One of the ways patients can help doctors with migraine management is by keeping detailed records, including a diary to identify triggers of migraines, time, duration, frequency and severity of attacks.129 Some patients find they can effectively treat themselves using low-cost over-the-counter drugs. For instance, a multicenter trial of an over-the-counter therapy containing acetaminophen/aspirin/caffeine (AAC) provided significantly better (more rapid and more sustained) relief than the prescription drug sumatriptan.130 Sumatriptan, sold under the brand name Imitrex, costs around $16 per tablet, regardless of the strength of the dose (25mg, 50mg or 100mg).131 Individuals suffering from the onset of a migraine headache can take up to 200mg of Sumatriptan per day.132 Patients who try AAC treatment may find they can save hundreds per year, and possibly see the doctor less frequently.

Economic Incentives . Because chronic disease is so costly, insurers and public health advocates hope that chronic disease management (CDM) will reduce costs and improve quality of life in chronically ill patients.133 The goal is to identify expensive-to-treat patients and reduce costs through better management of their disease before costly complications occur.

Patients may not be able to rely on their health insurers for disease management.134 The reason is that, for the most part, insurers and providers don’t benefit from the results. The efforts of health insurers to use disease management generally don’t pay off because patients do not stay enrolled in their plans long enough to recoup the investment. Furthermore, a recent study in Health Affairs found that when disease management was provided to broad populations of patients with chronic disease, overall costs generally rose rather than fell. The only group who benefited from disease management was the small subset of patients not following treatment protocols.135 For patients already adhering to protocols, additional expenditures to better manage their conditions generally result in higher marginal costs with little marginal benefit. But when patients control their own expenditures, and benefit from any savings they realize, they have an economic incentive to adhere to treatment protocols.

Patients also may not be able to rely on their doctors to manage their conditions. Physicians’ compensation is based on the services they render, rather than evaluations of their performance based on patient outcomes.136 Consequently, physicians have little incentive to counsel patients on disease management and follow up to see if recommendations were followed.

“When patients manage their own health care dollars, they have an economic incentive to adhere to treatment protocols.”

Patients benefit the most from disease management in terms of better health. If patients tend to reap most of the benefits, they should bear the cost and control the funds necessary to manage their chronic conditions. Since chronic conditions increase patients’ out-of-pocket costs, controlling the funds to manage their conditions is a step towards motivating them.137 Patients with health savings accounts would reap financial rewards (beside the reward of good health) since they would be at liberty to use fund for prevention rather than acute care.

[page]

State and federal regulation of medical care has not kept up with the technology now available to patients. Neither has it kept up with patients’ ability to easily participate in their own medical decisions.

Needed Reform: Laws on Physician Practice. In the United States, physicians are licensed by a state medical board to practice medicine. Many state medical boards find the practice of cyber-medicine unethical if a consultation does not involve face-to-face examinations.138 This makes practicing medicine online and across state borders difficult — if not illegal. Even rendering second opinions by way of the Internet is sometime problematic.139 For example, physicians working for the Web-based service MyDoc.com faced the threat of legal action for treating patients after having online consultations.140 However, 43 percent of Internet-using patients report seeking, in effect, a second opinion on a medical Web site. About one-third of patients on the Internet have sought the advice online of a physician other than their own.141

State medical licensing also restricts trade. A patient receiving a mammogram or body scan could request that the results be sent electronically to a high-tech facility in India to be interpreted by a highly trained Indian physician at a fraction of the cost of an American radiologist. Likewise, it would cut costs if a patient receiving comprehensive blood tests through a direct testing facility could choose a physician anywhere in the country (or world) to interpret the results. A few hospitals have arrangements with high-tech facilities staffed with Indian radiologists who interpret X-rays and scans at night when an American radiologist is not available. However, various state laws make this arrangement difficult unless the Indian radiologist is licensed in the state where the hospital is located or unless a state-licensed American physician signs off on the results.142

Needed Reform: Laws on Referrals. Regulation also affects how medical referrals are made. State and federal laws prevent practitioners from paying fees in return for patient referrals. Although this sounds like a good policy, it also has some negative ramifications. Blocking all referral fees makes it difficult to connect patients with providers of medical services.

“Blocking all referral fees makes it difficult to connect patients with medical service providers.”

Imagine a medical services auction Web site similar to eBay. Sellers could offer package deals for various medical services available at given time slots. Potential buyers could read feedback left by previous patients to ensure the service provider’s quality and honesty. Shady practitioners would be essentially blacklisted by accumulated negative feedback and no one would be willing to patronize them. But, because they are not able to charge physicians a referral fee, medical auction Web sites have to trust consumers to pay for completed services (although the patients have little incentive to do so after they have connected with a physician). And consumers are often difficult to track down since they likely only purchase services occasionally. Neglecting to report the purchase of the service to the Web site could save them $20 to $95 depending upon the procedure purchased. For this reason, most Web sites advertising medical services are promoting the services of individual medical practices rather than bringing together numerous physicians to compete on price to earn patients’ business. As a result, the online market for connecting buyers and sellers of medical services is small and uncompetitive compared to the numerous auction Web sites like eBay and Yahoo.

One medical auction Web site that does exist, BidForSurgery.com, connects cosmetic surgery providers with potential patients. Physicians compete for business on both quality and price. Patients are free to consider any offer made by a physician and schedule a complimentary consultation. Since cosmetic surgery is paid for out-of-pocket, patients are free to pick the physician of their choice. However, it is difficult for the Web site to collect fees for their services. Whereas Web sites selling airline tickets receive nominal fees from the airline whose ticket is sold (usually $5 to $10) — and the air traveler often also pays a nominal fee — BidforSurgery.com cannot make similar arrangements as easily. Since surgery is ultimately an arrangement between doctor and patient after a consultation, it is difficult to track and bill a patient whose services were successfully arranged. The most logical party to pay a “finder’s fee” would be physicians, since they stand to gain from performing numerous procedures, but they are not legally allowed to pay for referrals.

Like other Web sites, BidforSurgery.com earns revenue by displaying commercial advertising. However, selling advertising is not as lucrative as physicians paying referral fees per completed transaction. Thus the market for medical auction Web sites is not very competitive.

“Two-thirds of office visits to physicians result in prescription drug therapy because it is among the most efficient methods to treat illnesses.”

Needed Reform: Drug Regulation. Two-thirds of office visits to physicians result in prescription drug therapy because it is among the most efficient methods to treat illnesses.143 But only a licensed medical practitioner can prescribe prescription drugs. The only drugs that consumers can obtain without a prescription are those approved for sale over the counter. The process of moving a drug from prescription-only status to OTC status is called Rx-to OTC switching. Drug manufacturers usually request this switch when their patent protection is about to expire. In other words, OTC drugs are usually older therapies that have been replaced by a newer medicine. In many cases newer drugs are more effective than older, less expensive drugs.144

Restricting patent medications to the prescription-only market drives up consumers’ costs. Likewise, denying consumers access to any safe drug drives up treatment costs.145 The Food and Drug Administration (FDA) has recently shown a greater willingness to consider increasing patients’ access to formerly prescription-only drugs.146 Consequently, the number of drugs switched to OTC status is expected to increase 50 percent over the next few years.147 The FDA recently held public hearings to discuss possible changes in the criteria or inclusion of classes of drugs to consider for OTC status.148 A request initiated by WellPoint Health Networks (which manages health plans) to move second generation antihistamines (Claritin, Allegra and Zyrtec) from prescription-only status to over the counter was the first time an FDA panel voted to recommend OTC status when manufacturers hadn’t requested it and were opposed to the switch.149

Figure VIII - Annual Cost of Cholesterol Control

“Europe has approved four times as many prescription drugs as the United States for over-the-counter sale.”

Unfortunately, the FDA’s recent track record of moving medications to the OTC market is decidedly mixed. Europe approves far more drugs for OTC sales. Over the last two decades, for every drug switched from RX to OTC in the United States, Europeans have switched more than four.150 The FDA missed a chance to approve two power cholesterol-lowering drugs, Mevacor (Lovastatin) and Pravacol (Pravastatin), for OTC use in 2000.151 In January 2005 an FDA advisory panel again voted overwhelmingly against recommending Mevacor for over-the-counter sales.152 This is unfortunate because recent studies have shown how beneficial these drugs are in reducing coronary heart disease and heart attacks.153 Analysts hoped the FDA would eventually approve OTC sales of Lovastatin. However, Merck, the maker of Lovastatin, may not be willing to bear the cost of satisfying all the FDA’s queries. For instance, in the latest attempt to convince the FDA to switch Mevacor, Merck conducted trials with mock storefronts where observers studied consumers’ ability to self-diagnose high cholesterol, read product labels and follow directions. Despite an extensive study, the FDA did not think Merck had proved their case. The expense of submitting an RX-to-OTC petition to the FDA is high. And once the patent expires, opportunities to extend a drug’s profits quickly diminish over time.154 As a result, American consumers are denied OTC access to drugs that could significantly reduce treatment costs.155 [See Figure VIII.]

“Drugs for high blood pressure and cholesterol control are good candidates for overthe-counter status.”

Regulations are not so restrictive in some other developed countries. For example, the British have approved the OTC sale of a low-dose version of Merck’s newer drug Simvastatin under the brand name Zocor Heart Pro, with a short pharmacist consultation.156 The British Committee on Safety of Medicines recommended selling Simvastatin OTC after studies showed that Simvastatin can reduce LDL cholesterol (e.g. bad cholesterol) by 27 percent and the risk of heart attack of death from coronary heart disease by one-third after three years of treatment.157 Interestingly, European medical publications address the issue of “self-care” more frequently (and openly) than journals based in the United States. This may be one reason why Europe has switched far more prescription drugs to OTC status during the past two decades.158

Another consumer choice was effectively thwarted — some say for political reasons — when the FDA declined to allow sales of Plan B (emergency contraception) for OTC use.159 Both the FDA’s reproductive health drugs advisory committee and nonprescription drugs committee voted in favor of the OTC switch for Plan B in a joint meeting.160 However, 49 House Republican legislators sent a letter to President Bush voicing their view that it should not be made available without a prescription.161 Since this medication must be started within 72 hours of unprotected intercourse, requiring a doctor’s prescription effectively prevents access by women.

The FDA needs to make more medications available to the public over the counter — including those for chronic conditions. Easier access to drugs like statins for cholesterol, medications for high blood pressure and cardiac drugs to treat heart conditions all are good candidates for over-the-counter.

Some critics argue that self-treatment based upon information obtained from the Internet is not in patients’ best interest.162 However, patients could discuss treatment protocols with their physicians. They could also discuss the cost of various treatments and the trade-offs they are willing to make.163

“A different malpractice standard for e-mail (compared to in-person) consultations is needed.”

Needed Reform: Legal Liability. Physicians usually counsel patients on treatments and therapies in person and then write relevant information in the medical records based on the physicians’ observations. Whereas there is usually no complete documentation of phone conversations or examination room visits, an e-mail exchange is often an unfiltered transcript of patient and physician exchanges.164 Physicians may risk lawsuits if an e-mail exchange in the medical record is not concise in its explanation of patient treatments plans and does not conform to standards of accepted care protocols. A bigger problem is that there is no examination on which advice is given. The American Medical Association recommends that physicians establish guidelines for situations when e-mail correspondence is appropriate and when in-person office visits are preferred.165 A different malpractice standard for e-mail consultations (compared to in-person consultations) is needed so that physicians are not afraid to use e-mail with patients out of fear of malpractice suits. Legal reform should protect physicians following appropriate guidelines on patient/physician e-mail communication such as those established by the American Medical Informatics Association.166

[page]

Consumers now have numerous avenues to become smart shoppers of medical services. Research has shown that employees are more satisfied when they have a greater choice of plans and consumer-driven health care offers them the ultimate choice. With these new plans comes the opportunity to manage our own care.

An important byproduct is that the quality of health care and service improves when patients control the checkbook, rather than third-party insurers. Another important result is that costs will rise more slowly. Over 250 million consumers holding a tight rein on health care spending will do more to control costs than a few third-party bureaucrats working for HMOs.

NOTE: Nothing written here should be construed as necessarily reflecting the views of the National Center for Policy Analysis or as an attempt to aid or hinder the passage of any bill before Congress.

[page]
  1. Regina E. Herzlinger, ed., Consumer-Driven Health Care: Implications for Providers, Payers, and Policymakers (San Francisco, Calif.: Jossey-Bass, 2002), page xvii.
  2. The Rand Health Insurance Experiment tested this theory extensively. See Joseph page Newhouse, Free for All?: Lessons from the Rand Health Insurance Experiment (Cambridge Mass: Harvard University Press, January 1994).
  3. Katharine Levit, et al., “Trends in U.S. Health Care Spending, 2001,” Health Affairs, Vol. 22, No.1, January/February 2003, pages 154-164.
  4. Don R. Powell, “Implementing a Medical Self-Care Program,” Employee Benefits Journal (International Foundation of Employee Benefit Programs), September 2003.
  5. Gina Kolata, “Annual Physical Checkup May Be an Empty Ritual,” New York Times, August 12, 2003.
  6. See Occupational Health Management, “Self-Care Can Save Millions in Health Costs: Unnecessary Visits to ED, other Costs Avoided,” Occupational Health Management, November 2001.
  7. John C. Goodman, “Health Savings Accounts will Revolutionize American Health Care,” National Center for Policy Analysis, Brief Analysis No. 464, January 15, 2004.
  8. Cristiano Antonelli, Aldo Geuna and W. Edward Steinmueller, “Information and Communication Technologies and the Production, Distribution and Use of Knowledge,” International Journal of Technology Management, Vol. 20, No. 1/2, 2000, pages 72-94.
  9. Susannah Fox and Deborah Fallows, “Internet Health Resources,” Pew Internet and American Life Project, July 16, 2003.
  10. In 1999, Bob Pringle, president of health content provider Inteli-health, estimated 15,000 to 20,000 Web sites dedicated to health-related content. See Robert McGarvey, “Online Health’s Plague of Riches,” The Tech Insider, September 29, 1999. The Internet Healthcare Coalition claims more than 20,000 Web sites dedicated to health care. See “Tips for Healthy Surfing Online,” Internet Healthcare Coalition, 2002. This is consistent with estimates from the Journal of Medical Internet Research. See Roberto J. Rodrigues, “Ethical and Legal Issues in Interactive Health Communications: A Call for International Cooperation,” Journal of Medical Internet Research, Vol. 2, No. 1, 2001.
  11. Mary Chris Jaklevic, “Medical Data Accessible on Internet,” Modern Healthcare, Vol. 26, No. 19, May 2, 1996, page 82.
  12. Joseph A. Diaz, Rebecca A. Griffith, James J. Ng, Steven E. Reinert, Peter D. Friedmann, and Anne W. Moulton, ”Patients’ Use of the Internet for Medical Information,” Journal of General Internal Medicine, Vol. 17, No. 3, March 2002, pages 180-85.
  13. Joel S. Weissman et al., “Patient Encounters Involving Direct-To-Consumer Advertising,” Health Affairs, Web Exclusive, April 28, 2004.
  14. Meredith B. Rosenthal et al., “Promotion of Prescription Drugs to Consumers,” New England Journal of Medicine, Vol. 346, No. 7, February 14, 2002, pages 498-505.
  15. Alan F Holmer (Pharmaceutical Research & Manufacturers of America), “Pharmaceutical Careers in the USA,” Available online at www.medical-colleges.net/pharmaceutical4.htm. Access verified on February 23, 2005.
  16. Due to many of the advances in treatment of heart disease mentioned in the text, the age-adjusted death rate from heart disease has fallen by 56 percent since 1956. Death rates from stroke have fallen by 70 percent since 1950. See Centers for Disease Control and Prevention, “Achievements in Public Health, 1900-1999: Decline in Deaths from Heart Disease and Stroke — United States, 1900-1999, Morbidity and Mortality Weekly Report, Vol. 48, No. 30, August 6, 1999, pages 649-656. For a history of advances in treating heart disease, see David M. Cutler, Your Money or Your Life: Strong Medicine for America’s Health Care System (New York: Oxford University Press, 2004).
  17. The American Heart Association has a wealth of information available to patients and practitioners alike on its Web site www.AmericanHeart.org.
  18. Pharmaceutical Research and Manufacturers of America, “Two Decades of Progress in Heart Disease Medicines Improving Cardiovascular Health,” Press Release, February 03, 2005.
  19. Grace L. Johnson and Arkalgod Ramaprasad, “Patient-Physician Relationships in the Information Age,” Marketing Health Services Vol. 20, No. 1, Spring 2000, pages 20-27. Also see Ben S. Gerber and Arnold R. Eiser, “The Patient-Physician Relationship in the Internet Age: Future Prospects and the Research Agenda,” Journal of Medical Internet Research, Vol. 3, No. 2, 2001.
  20. Johnson and Ramaprasad, “Patient-Physician Relationships in the Information Age,” pages 20-27.
  21. Ruth Larson, “Medical Advances Can Outpace Doctors; Retraining Not Enforced, Critics Say,” Washington Times, March 21, 1999.
  22. Physicians admitted to the board prior to a certain date are grandfathered in and exempt from periodic examination. See Sandra G. Boodman, “Study: Veteran Doctors Not Staying Current,” Washington Post, February 22, 2005, page HE01.
  23. Kimberly S. H. Yarnall, et al., “Primary Care: Is There Enough Time for Prevention?” American Journal of Public Health, Vol. 93, No. 4, April 2003. For the latest report on preventative screen guidelines see U.S. Preventive Services Task Force, “Guide to Clinical Preventive Services, 3rd Edition: Periodic Updates,” Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Report of the U.S. Preventive Services Task Force, October 2002. Available online at http://www.ahrq.gov/clinic/gcpspu.htm.
  24. Sally Trude, “So Much to Do, So Little Time: Physician Capacity Constraints, 1997-2001,” Center for Studying Health System Change, Tracking Report No. 8, May 2003.
  25. Kevin Patterson, “What Doctors Don’t Know (Almost Everything),” New York Times Magazine, May 5, 2002, pages 74-77.
  26. For examination of the literature on doctor-patient communication, see Ronald M. Epstein, Brian S. Alper and Timothy E. Quill, “Communicating Evidence for Participatory Decision Making,” Journal of the American Medical Association, Vol. 291, No. 19, May 19, 2004.
  27. K. Binns and Q. Homan, “Consumers Demand Personalized Services to Manage Their Health,” ADVANCE for Health Information Executives, Vol. 5, 2001, page 88.
  28. See Ronald M. Epstein, Brian S. Alper and Timothy E. Quill, “Communicating Evidence for Participatory Decision Making,” Journal of the American Medical Association, Vol. 291, No. 19, May 19, 2004.
  29. Robert J. Blendon, et al., “Views of Practicing Physicians and the Public on Medical Errors,” New England Journal of Medicine, Vol. 347, No. 24, December 12, 2002, pages 1933-40.
  30. For a discussion, see James G. Anderson, “How the Internet Is Transforming the Physician-Patient Relationship,” Medscape TechMed eJournal, Vol.1, No. 3, 2001.
  31. See Barbara Starfield, “Is Primary Care Essential?” Lancet 344, No. 8930, October 22, 1994, pages 1129-33.
  32. Matthew K. Wynia, et al., “Do Physicians Not Offer Useful Services Because Of Coverage Restrictions?” Health Affairs, Vol. 22, No. 4, July/August 2003, pages 190-197.
  33. Alain Enthoven and Sara J. Singer, “The Managed Care Backlash and the Task Force in California,” Health Affairs, Vol. 17, No. 4, July/August 1998, pages 95-110. Also see Robert J. Blendon, et al., “Understanding the Managed Care Backlash,” Health Affairs, Vol. 17, No. 4, July/August 1998, pages 80-94.
  34. Kimberly Blanton, “Putting a Premium on Healthy Behavior,” Boston Globe, February 17, 2005.
  35. “Employer Health Benefits 2004 Annual Survey,” The Kaiser Family Foundation and the Health Research and Educational Trust, September 9, 2004.
  36. “U.S. Health Benefit Costs Rises 7.5% in 2004, Lowest Increase in Five Years,” Mercer Human Resource Consulting, Press Release, November 22, 2004.
  37. Ibid.
  38. Ken Terry, “Tame Your Health Insurance Costs: Here are Some Practical Ways to Cut Your Premiums and Help your Employees Pay Theirs. But Don’t Expect Rates to Level Off Anytime Soon,” Medical Economics, February 4, 2005.
  39. “Healthcare Coverage; Insurance Company Launches New Health Plans and Health Savings Accounts,” Managed Care Weekly Digest, February 28, 2005.
  40. Jon R. Gabel, Anthony T. Lo Sasso, and Thomas Rice, “Consumer-Driven Health Plans: Are They More Than Talk Now?” Health Affairs, Web Exclusive, November 20, 2002.
  41. “Growth of HSAs, HDPHs Could Translate to Shrinking Health-Plan Revenues, Report Says,” Inside Consumer-Directed Care,” Vol. 3, No. 6, March 18, 2005.
  42. This section is based on John C. Goodman, “Health Savings Accounts Will Revolutionize American Health Care,” National Center for Policy Analysis, Brief Analysis No. 464, January 15, 2004.
  43. Revenue Procedure 2004-71, Internal Revenue Service, U.S. Department of the Treasury, November 19, 2004.
  44. For a comprehensive guide to how HSAs work, see Dan Perrin, “HSA Road Rules: for Consumers, Employers, Insurers, Banks, Credit Unions and Administrators,” The HSA Coalition, December 7, 2004. Available online at http://www.hsainsider.com/HSA%20Road%20Rules%20Dec%207th.pdf.
  45. This section is based on Michael F. Cannon, “Three Avenues to Patient Power,” National Center for Policy Analysis, Brief Analysis No. 430, January 30, 2003.
  46. Devon M. Herrick, “The Internet and Non-Profit Disease Advocacy: An Empirical Analysis,” Ph.D. dissertation, University of Texas at Dallas, 2003, unpublished.
  47. Joan Stephenson, National Library of Medicine to Help Consumers Use Online Health Data, The Journal of the American Medical Association, Vol. 283, No. 13, April 15, 2000, pages 1675-76.
  48. Leslie Miller, “Guidelines Offer Cures for Web Confusion,” USA TODAY, July 15, 1999.
  49. Susan J. Landers, “Rx Isn’t Just Medication Anymore,” American Medical News, May 24/31, 2004.
  50. For more information, see the Center for Information Therapy, Web site www.informationtherapy.org.
  51. Susan J. Landers, “Web Sites Can Give Patients Info They Need for Decisions,” American Medical News, January 26, 2004. For more information on shared decision making, see Peter Briss, et al. (Task Force on Community Preventive Services), “Promoting Informed Decisions about Cancer Screening in Communities and Healthcare Systems,” American Journal of Preventive Medicine, Vol. 26, No. 1, January 2004, pages 67-80; Stacey L. Sheridan, et al., “Shared Decision Making about Screening and Chemoprevention: A Suggested Approach from the U.S. Preventive Services Task Force,” American Journal of Preventive Medicine, Vol. 26, No. 1, January 2004, pages 56-66; Robert M. Kaplan (Editorial), “Shared Medical Decision Making: A New Tool for Preventive Medicine,” American Journal of Preventive Medicine, Vol. 26, No. 1, January 2004, pages 81-83.
  52. Based on a poll of 1,001 people taken by Harris Interactive between May 26, 2000, and June 10, 2000. For data on what they are seeking, see “ Evolution of Internet Use for Health Purposes – Feb/Mar 2001,” Health on the Net Foundation.
  53. “Patients Want Online Communication With Their Doctors,” Medscape Medical News, April 17, 2002 and “Patient/Physician Online Communication: Many Patients Want it, Would Pay for it, and it Would Influence their Choice of Doctors and Health Plans, Harris Interactive Healthcare News, Vol. 2, No.8, April 10, 2002.
  54. Sandra G. Boodman, “Calling Doctor Dappen,” Washington Post, September 9, 2003. Also see Mike Norbut, “Doctor Redefines Visits with Phone, E-mail,” American Medical News, October 20, 2003.
  55. Of the 14 percent who reported e-mail exchanges with their physician, 12.7 percent said it was occasional. Slightly less than 37 percent of physicians report e-mail contact with patients “occasionally” and about 8 percent report e-mail contact frequently. See data from “Evolution of Internet Use for Health Purposes – Feb/Mar 2001,” Health on the Net Foundation.
  56. Christine Wiebe, “Doctors Still Slow to Adopt Email Communication,” Medscape Money & Medicine, Vol. 2, No. 2, 2001.
  57. Milt Freudenheim, “Digital Rx: Take Two Aspirins and E-Mail Me in the Morning,” New York Times, March 2, 2005.
  58. Ibid.
  59. David Koenig (Associated Press), “A Few Doctors Seeing Patients Online,” Akron Beacon Journal (Ohio.com), December 21, 2003.
  60. A billing code is a standardized charge facilitating reimbursement for physician services and payment by insurers or patients. These codes are used for record-keeping purposes as well. For instance, the billing code (and the amount paid) for a physician e-mail exchange would be different than the code for an in-person office visit. See David Koenig (Associated Press), “A Few Doctors Seeing Patients Online,” Akron Beacon Journal (Ohio.com), December 21, 2003.
  61. Warner V. Slack, “A 67-Year-Old Man Who e-Mails His Physician,” Journal of the American Medical Association, Vol. 292, No. 18, November 10, 2004, pages 2255-2261.
  62. Mike Norbut, “Doctor Redefines Visits with Phone, E-mail,” American Medical News, October 20, 2003.
  63. For a discussion, see Michael Johnsen, “Swifter Rx-to-OTC Switches are Hot Topic at CHPA Meeting,” Drug Store News, Dec 16, 2002.
  64. For a discussion of in-home diagnostic laboratory tests in layman’s terminology, see Sarah Tippit, “Home Medical Tests,” Better Homes & Gardens, January 1997.
  65. Pan Demetrakakes, “Health Kit Packaging Helps Consumers Feel at Home with Self-Care: Packaging for Home Health Monitoring Devices Combines Health-Care Concerns with Appeal to both Consumers and Retailers,” Food & Drug Packaging, February 2003.
  66. Price and availability confirmed August 8, 2004 at “Always 1 Dollar Store,” Mesquite, Texas.
  67. Charlotte LoBuono, “Taking Advantage of Home Testing and Monitoring,” Patient Care, February 15, 2000.
  68. Maureen Donohue, “OTC Home Kits Provide New Diagnostic Options,” Family Practice News, February 15, 2001.
  69. W. Fred Miser, “To Treat or not to Treat Otitis Media — that’s just one of the Questions,” Journal of the American Board of Family Practice. Vol. 14, No. 6, 2001, pages 474-476.
  70. Tom Ferguson, “Ear Infection Detector,” Whole Earth, Winter 2002.
  71. Tom Ferguson, “Home Strep Test Kit,” Whole Earth, Winter 2002.
  72. Doug Brunk, “FDA Approves Home Test Kit for Menopause: Experts Question its Value,” OB/GYN News, January 15, 2002. Also see Mary Duenwald, “Over-the-Counter Menopause Test Kits Offer Few Answers,” New York Times, August 17, 2004.
  73. Ann Donahue, “Firm Unveils Device that Tests Blood,” Los Angeles Business Journal, January 3, 2000.
  74. Wilson, Kevin, “Online Access to Test Results for Doctors and Patients,” MLO: Medical Laboratory Observer, Vol. 32, No. 3, March 2000, page 8.
  75. Information obtained from the HS Labs Web site www.BloodWorksUSA.com.
  76. Information obtained from the Direct Laboratory Services, Inc. Web site www.DirectLabs.com.
  77. Anne Harding, “Do it Yourself Cancer Gene Testing Raises Concerns,” British Medical Journal, Vol. 330, No. 7492, March 19, 2005, page 617.
  78. John J. Paris, “Ethical Issues in Cybermedicine: Patent-Medicine Salesmen did not go out of Style with the Conestoga Wagon,” America, Vol. 184, No. 4, February 23, 2001, pages 15-24.
  79. For a discussion of patient attitudes and potential risks, see Lisa M. Schwartz et al., “Enthusiasm for Cancer Screening in the United States,” Journal of the American Medical Association, Vol. 291, No. 1, January 7, 2004, pages 71-78.
  80. Susan J. Landers, “Full-body Scans: Buying Peace of Mind,” American Medical News, September 3, 2001.
  81. Roger Jones, “Self Care” British Medical Journal Vol. 320, No. 7235, March 4, 2000, page 596.
  82. Roger Jones and D Murfin, ed. Gastrointestinal Problems in General Practice (Oxford: OUP, 1993).
  83. Ted R. Tyson, “The Internet: Tomorrow’s Portal to Non-Traditional Health Care Services,” Journal of Ambulatory Care Management, Vol. 23, No. 2, April 2000, pages 1-7.
  84. “Fact Sheet: The Use of Over-the-Counter Medicines,” National Council on Patient Information and Education, January 2002.
  85. Simon Rottenberg, “Unintended Consequences: The Probable Effects of Mandated Medical Insurance,” Regulation, Vol. 13, No. 2, Summer 1990, pages 27-28.
  86. Nancy K. Lowe and Nancy M. Ryan-Wenger, “Over-the-Counter Medications and Self-Care,” Nurse Practitioner, December 1999. See, “Ingredients & Dosages Transferred From Rx-to-OTC Status (or New OTC Approvals) by the Food and Drug Administration Since 1975,” Consumer Healthcare Products Association, July 2003. Available online at http://www.chpa-info.org/web/advocacy/general_issues/switch/switch_list.pdf.
  87. Ibid.
  88. Sandra Levy, “Health Plans Pleased with Allergy Drug’s OTC Switch,” Drug Topics, December 16, 2002.
  89. FDAnews, “OTC Claritin to Hit Markets by Mid-December,” FDAnews Daily Bulletin, FDAnews.com, December 3, 2002.
  90. Chemical Market Reporter, “Claritin Receives OTC Status, Chemical Market Reporter, December 2, 2002.
  91. Time period for sales of antihistamines was September 2001 to September 2002. See Michael Johnsen, “Redefined Rx-to-OTC Switch Model May Reshape Sales Landscape,” Drug Store News, January 20, 2003.
  92. “OTC Prilosec One Step Closer in US,” Pharmafocus News, June 26, 2002; “Prilosec OTC Launch Delayed, Pharmafocus News, November 4, 2002.
  93. “At-Home Defibrillator in Stores Soon,” WebMD Medical News, November 13, 2002. Also see Daniel DeNoon, “FDA Panel OKs No-Prescription Sales of Home Defibrillator,” WebMD Medical News, August 6, 2004.
  94. Associated Press, “FDA Approves Defibrillator for At-Home Use,” USA Today, November 11, 2002. The discounted price at Drugstore.com was $1,495 in 2005.
  95. Devon Herrick, “Shopping for Drugs: 2004, National Center for Policy Analysis, NCPA Policy Report No. 270, October 11, 2004.
  96. Gerard Anderson et al., “Chronic Conditions: Making the Case for Ongoing Care,” Partnership for Solutions (The Robert Wood Johnson Foundation and Johns Hopkins University), September 2004. Available online at http://www.partnershipforsolutions.com/DMS/files/chronicbook2004.pdf.
  97. Benjamin Druss et al., “Comparing the National Economic Burden of Five Chronic Conditions,” Health Affairs, Vol. 20, No. 6, November/December 2001, pages 233-241.
  98. “Heart Disease and Stroke Statistics — 2005 Update,” American Heart Association, 2005.
  99. David M. Cutler, Your Money or Your Life: Strong Medicine for America’s Health Care System (New York: Oxford University Press, 2004).
  100. Randal S. Stafford and David C. Radley, “The Potential of Pill Splitting to Achieve Cost Savings,” American Journal of Managed Care, Vol. 8, No. 8, August 2002, pages 706-12.
  101. “Diuretics Proved to be Superior to other, more Expensive Anti-hypertensive Drugs,” Healthfacts, January 2003.
  102. ALLHAT Collaborative Research Group, “Major Outcomes in High-Risk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs. Diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT),” Journal of the American Medical Association, Vol. 288, No. 23, December 18, 2002, pages 2981-2997.
  103. Mitchel L. Zoler, “Home HT Monitoring Cuts Office Visits by 27%, “Family Practice News, January 1, 2000.
  104. Philip B. Gorelick, “Aspirin and Ticlopidine for Prevention of Recurrent Stroke in Black Patients,” Journal of the American Medical Association, Vol. 289, No. 22, June 11, 2003, pages 2947-2957.
  105. Price comparisons were obtained from DestinationRX.com. A patient taking two (250mg) tablets per day purchased in quantities of 60 tablets per month would spend $63.60 per month at AARP.
  106. American Diabetes Association, “Improved Diabetes Control Yields ‘Zest for Life’,” PRNewswire, June 14, 2000.
  107. “Diabetes Statistics,” U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, NIH Pub. No. 96-3926, 1995.
  108. Patti Bazel Beil and Laura Hieronymus, “Money-Saving Tips: Supplies, Nutrition, and Exercise,” Diabetes Self-Management, March/April 1999.
  109. “Economic and Health Costs of Diabetes,” Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, Healthcare Cost and Utilization Project Highlights, No. 1, AHRQ Pub. No. 05-0034, January 2005.
  110. Susan L. Norris, Michael M. Engelgau and K. M. Venkat Narayan, “Effectiveness of Self-Management Training in Type 2 Diabetes,” Diabetes Care, March, 2001.
  111. Teresa Pearson, “Getting the Most From Health-Care Visits,” Diabetes Self-Management, March/April 2001.
  112. “Self-Monitoring of Blood Glucose,” Clinical Diabetes, Winter 2002.
  113. Patti Bazel Beil and Laura Hieronymus, “Money-Saving Tips: Supplies, Nutrition, and Exercise,” Diabetes Self-Management, March/April 1999.
  114. Prices found on www.Froogle.com, www.devinemedical.us and www.walgreens.com.
  115. eBay auction March 14, 2005.
  116. Joe A. Florence and Bryan F. Yeager, “Treatment of Type 2 Diabetes Mellitus,” American Family Physician, Vol. 59, No. 10, May 15, 1999.
  117. For techniques to lower one’s drug bill, see Devon M. Herrick, “Shopping for Drugs: 2004,” National Center for Policy Analysis, NCPA Policy Report No. 270, October 2004.
  118. Patti Bazel Beil and Laura Hieronymus, “Money-Saving Tips: Supplies, Nutrition, and Exercise,” Diabetes Self-Management, March/April 1999.
  119. Tjard R. Schermer, et al., “Randomized Controlled Economic Evaluation of Asthma Self-Management in Primary Health Care,” American Journal of Respiratory and Critical Care Medicine Vol. 166, No. 8, August 2002, pages 1062-1072. For an evaluation of direct medical treatment costs for asthma, see Michael T. Halpern, et al., “Asthma: Resource Use and Costs for Inhaled Corticosteroid vs Leukotriene Modifier Treatment—a Meta-Analysis,” Journal of Family Practice, May 23, 2005.
  120. “Asthma Overview,” Asthma and Allergy Foundations of America, Internet. Available online at http://www.aafa.org/display.cfm?id=8&cont=5.
  121. Li Yan Wang, Yuna Zhong and Lani Wheeler, “Direct and Indirect Costs of Asthma in School-age Children,” Preventing Chronic Disease, Vol. 2, No. 1, January 2005.
  122. Ibid. Implementation costs were mostly incurred in year one and amounted to about $200.
  123. See “Take Control – Q&A to Having a Self Management Plan,” AsthmaAssistant.com. For instance, an asthma self-management plan could stipulate that if a patient’s “peak airflow” falls to 80 percent of their personal best peak airflow, they should increase medications at a pre-established rate and schedule a physician appointment. Patients should go to the emergency room if their peak airflow falls below 50 percent.
  124. For information see http://www.asthmaassistant.com.
  125. Joseph Finkelstein and Manuel R. Cabrera, “Internet-Based Home Asthma Telemonitoring,” Chest (American College of Chest Physicians), Vol. 117, No. 1, January 2000, pages 148-155.
  126. Bruce Jancin, “Warfarin Home Self-Monitoring,” Family Practice News, April 1, 2000.
  127. National Headache Foundation Fact Sheet, January 8, 2003.
  128. The direct medical cost of headaches (including migraines) and absenteeism from headaches is estimated at $50 billion per year. In addition, consumers spend $4 billion per year on over-the-counter pain relievers for headaches. See National Headache Foundation Fact Sheet, January 8, 2003.
  129. “5 Effective Strategies for Migraine Management,” National Headache Foundation, undated. Available online at http://www.headaches.org/consumer/presskit/NHAW04/Five_Steps.pdf.
  130. When combination therapy was taken at the first sign of a migraine headache. See Patrice G.W. Norton, “OTC Product Beats Sumatriptan for Early Migraine: Study of 171 Patients – Clinical Rounds,” OB/GYN News, September 15, 2003.
  131. Nine tablets cost $147 at RxUSA.com for the 25mg, 50mg and 100mg dose.
  132. U.S. National Library of Medicine, Drug Information, Available online at http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a601116.html.
  133. See Ben Wheatley, “Medicaid Disease Management: Seeking to Reduce Spending by Promoting Health,” Academy for Health Service Research and Health Policy, State Coverage Initiatives, Issue Brief, August 2001 and Robert E. Mechanic, “Disease Management: A Promising Approach for Health Care Purchasers,” National Health Care Purchasing Institute, May 2002.
  134. For a good discussion of this issue, see Roger Lowenstein, “The Quality Cure,” New York Times, March 13, 2005.
  135. Ben Fireman, Joan Bartlett, and Joe Selby, “Can Disease Management Reduce Health Care Costs by Improving Quality?” Health Affairs, Vol. 23, No. 6, November/December 2004. For a commentary see Francis J. Crosson and Philip Madvig, “Does Population Management of Chronic Disease Lead To Lower Costs Of Care? Health Affairs, Vol. 23, No. 6, November/December 2004.
  136. Roger Lowenstein, “The Quality Cure,” New York Times, March 13, 2005.
  137. Gerard Anderson, “Chronic Conditions: The Cost and Prevalence of Chronic Conditions are Increasing. A Response is Overdue,” National Institute for Health Care Management, Expert Voices, Issue 4, January 2002.
  138. The AMA has come out against prescribing medication over the Internet prior to a physical examination. Richard F. Corlin, President, American Medical Association (Letter to the editor ). “AMA to The Wall Street Journal: Shut Down Illegal Internet Pill Pushers,” The Wall Street Journal, November 6, 2001.
  139. Laws vary by state. Some “cyber docs” skirt the law by rendering only second opinions. For a discussion on e-practice patterns, see Tom Ferguson, “From Doc-Providers to Coach-Consultants: Type 1 vs. Type 2 Provider-Patient Relationships,” The Ferguson Report, Number 7, September 2001.
  140. Mike Norbut, “Doctor Redefines Visits with Phone, E-mail,” American Medical News, October 20, 2003.
  141. Data from survey “Evolution of Internet Use for Health Purposes – Feb/Mar 2001,” Health on the Net Foundation, 2001.
  142. Andrew Pollack, “Who’s Reading Your X-Ray?” New York Times, November 16, 2003. To read more about the benefits of outsourcing, see Douglas Irwin, “Outsourcing is Good for America,” Wall Street Journal, January 28, 2004.
  143. National Center for Health Statistics, cited in “Many Patients Receiving Medication,” USA Today Snapshots, USA Today, January 31 – February 2, 2003.
  144. Frank Lichtenberg, “Benefits and Costs of Newer Drugs: An Update,” National Bureau of Economic Research, Working Paper No. 8996, June 2002.
  145. Devon Herrick, “Patient Power: Access to Drugs,” National Center for Policy Analysis, Brief Analysis No. 500, February 10, 2005.
  146. Devon Herrick, “Shopping for Drugs: 2004,” National Center for Policy Analysis, NCPA Policy Report No. 270, October 11, 2004.
  147. Tufts Center for the Study of Drug Development, “Switching drugs from prescription to OTC status on rise in U.S. and EU,” Impact Report, Tufts Center for the Study of Drug Development, Tufts University, Vol. 5, No. 5, September/October 2003.
  148. Food and Drug Administration, “Over-the-Counter Drug Products; Public Hearing,” Food and Drug Administration, Department of Health and Human Services, (Docket No. 00N-1256) April 26, 2003.
  149. Holly M. Spencer, “The Rx-to-OTC Switch of Claritin, Allegra, and Zyrtec: An Unprecedented FDA Response to Petitioners and the Protection of Public Health,” American University Law Review, Vol. 51, No. 5, June 2002, pages 999-1050.
  150. Tufts Center for the Study of Drug Development, “Switching drugs from prescription to OTC status on rise in U.S. and EU,” Impact Report, Tufts Center for the Study of Drug Development, Tufts University, Vol. 5, No. 5, September/October 2003.
  151. Elizabeth Mechcatie, “FDA Panels Reject Making Low-Dose Statins Available OTC,” Family Practice News, September 1, 2000.
  152. For a discussion of over-the-counter access to Mevacor, see Devon M. Herrick, “Patient Power: Access to Drugs,” National Center for Policy Analysis, Brief Analysis No. 500, February 10, 2005.
  153. Eric J. Topol, “Intensive Statin Therapy — A Sea Change in Cardiovascular Prevention,” New England Journal of Medicine, Vol. 350, No. 15, April 8, 2004, pages 1562-1564; Penny KrisEtherton and T. A. Pearson, “Over-the-Counter Statin Medications: Emerging Opportunities for RDs,” Journal of the American Dietetic Association, October 2000.
  154. Lisa Jarvis, “Rx-OTC Switches Provide Strategy Against Expiry – Over the Counter Drugs,” Chemical Market Reporter, December 4, 2000.
  155. Drug makers think the prospects for an OTC statin are improving. See Associated Press, “Drug Makers Propose OTC Cholesterol Drugs,” Aetna Intelihealth, Health News, (intelihealth.com), May 14, 2004.
  156. Shaoni Bhattacharya, “Heart Wonder Drug goes Over-the-Counter,” New Scientist New Service (NewScientist.com), May 13, 2004.
  157. Rory Collins et al. (Heart Protection Study Collaborative Group), “MRC/BHF Heart Protection Study of Cholesterol Lowering with Simvastatin in 20,536 High-Risk Individuals: A Randomised Placebo-Controlled Trial,” Lancet, Vol. 360, No. 9326, July 6, 2002, pages 7-22.
  158. Over the last 20 years, Europe has switched about four times the number of prescription drugs to OTC status as the United States. See Tufts Center for the Study of Drug Development, “Switching drugs from prescription to OTC status on rise in U.S. and EU,” Impact Report, Tufts Center for the Study of Drug Development, Tufts University, Vol. 5, No. 5, September/October 2003.
  159. Jeffrey M. Drazen, Michael F. Greene and Alastair J.J. Wood, “The FDA, Politics and Plan B,” New England Journal of Medicine, Vol. 350, No. 15, April 8, 2004, pages 1561-1562.
  160. Elizabeth Mechcatie, “Panel Backs OTC Switch for Plan B: Emergency Contraception,” OB/GYN News, January 15, 2005.
  161. Mary Ellen Schneider, “GOP Opposes OTC Status – Policy & Practice,” OB/GYN News, February 15, 2004.
  162. See an argument against OTC access to cholesterol-lowering drugs because consumers are not in a position to self-diagnose and treat high cholesterol, in Sidney Goldstein, “Over-the-Counter Statins?” Family Practice News, September 1, 2000.
  163. A model for this is discussed in Tom Ferguson’s “Looking Ahead: Online Health & the Search for Sustainable Healthcare,”The Ferguson Report, Number 9, September 2002. See alsoKevin Patterson, “What Doctors Don’t Know,” pages 74-77.
  164. John W. Jones, Jr., “Liability for Electronic Medical Communications,” Physician’s News Digest, May 2000.
  165. “Guidelines for Physician-Patient Electronic Communications,” American Medical Association, June 2002. Available online at http://www.ama-assn.org/ama/pub/category/2386.html.
  166. Beverley Kane and Daniel Z. Sands (AMIA Internet Working Group, Task Force on Guidelines for the Use of Clinic–Patient Electronic Mail), “Guidelines for the Clinical Use of Electronic Mail with Patients,” Journal of the American Medical Informatics Association, Vol. 5, No. 1, Jan/Feb 1998.
[page]

Devon Herrick, Ph.D., is a senior fellow with the National Center for Policy Analysis. He concentrates on such health care issues as Internet-based medicine, health insurance and the uninsured, and pharmaceutical drug issues. His research interests also include managed care, patient empowerment, medical privacy and technology-related issues.

Dr. Herrick received a Ph.D. in Political Economy and a Master of Public Affairs degree from the University of Texas at Dallas with a concentration in economic development. He also holds an MBA with a concentration in finance from Oklahoma City University and an MBA from Amber University, as well as a BS in accounting from the University of Central Oklahoma.