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                 Thanks to Gianni for permission to use this Photo.

Daniel Carlat, of the Carlat Report, has an article in the New York Times Magazine.  It’s six pages long, and decidedly anti-Pharma.  But Daniel Carlat isn’t from New York– so why would he have an article published there?

You say: well, where he’s from has nothing to do with it, the New York Times is publishing it because of what he says.

Exactly.

His article, well written and persuasive, stands as is, undisputed because there is no forum in which to dispute it.  I guess it would be nice if the Times would allow me to write an op-ed– you know, in op to the ed– but I guess this blog will have to do.

Carlat is wrong, very wrong, not because he is factually incorrect about his target, but because his target is a straw man.  The problem isn’t Pharma.  It’s doctors.

The article, called Dr. Drug Rep, chronicles his introduction into the world of lecturing for drug companies– a company hires you to give a talk about a topic or drug to a bunch of doctors– and the effects of the lecturing on doctors and himself, and then his pulling out.  For context, Carlat is a fairly famous psychiatrist blogger who is both a sort of watchdog of Pharma, as well as a source of information about psychiatric drugs. 

The general message is that Pharma softly manipulates doctors to act as proxy drug reps, which in turn lends credibility/celebrity endorsement to the Pharma message, and thus influences other doctors to prescribe the medicine.  Ok, I hear you.  I have no beef with Carlat, his point is not unique.

But break it down:

So we don’t want doctors lecturing about the drugs.  Okay.  Well, who do we want?  More reps?  Here’s where it all falls apart, and I defy anyone to contradict me: doctors aren’t studying these drugs on their own. (more…)

                 Thanks to Natalie for permission to use this Photo.

We Americans are proud of our work ethic. We work longer hours, and more productively, than any other nation. Our industriousness has long been cited as a source of strength of our economy—but it just might be a source of some of our health care woes as well. 

According to a just-released study from Wake Forest University, professional flexibility is an important contributor to better health. Employees at all levels who have, or feel they have, more job flexibility (e.g. the ability to work from home, choose their hours, etc.) engage in healthier behavior than those that don’t. The study found that employees with flexible schedules exercised more, attended more employer-sponsored health classes, were more likely to describe themselves as living a healthy lifestyle, and reported getting more sleep. When the researchers checked in a year later, they found that as job flexibility improved, so did healthy habits: more flexibility meant more sleep, more health classes, and a healthier lifestyle.

This study deserves attention. Changing behavior is the single most powerful way to prevent health problems. As experts from the Robert Wood Johnson Foundation noted in a Health Affairs article earlier this year, “behavioral issues represent the greatest single domain of influence on the health of the U.S. population,” with 40 percent of early deaths in the U.S. due to behavioral patterns. Anything that promotes health behavior needs to be seriously considered as a strategy for making America healthier—and by extension, health care costs lower. 

Obviously, somehow ensuring that everyone in America had more flexible hours wouldn’t cut early deaths by 40 percent. And there’s no guarantee that more flexible hours will translate into better sleep, more exercise, or more education on a national scale. Any movement for universal job flexibility would have to be coupled with a concerted effort to translate free time into healthy time. (more…)

             Thanks to sidewalkstory for permission to use this Photo.

Should people be worried about the security of their health information?  In the past, I used to believe that perhaps the issues of security and privacy (an issue that is related to but NOT identical to security) were overblown.  I would go so far as to suggest that those with vested interests used these two issues to maintain control and prevent sharing of information (that was the cynic in me).  Around the same time, I also held a similar idea that patients didn’t really concern themselves with privacy so much.  Most patients assume that health providers share information as needed and that explicit consent to share information between providers was the strangest (if not the dumbest) thing.  I also believed that health care organizations seemed relatively secure, based on the measures they take which include triple identity verification and limiting remote access.

Today, I’m not so sure if I feel as confident about the security of my health information.  Recently, a family member of mine was almost a victim of fraud (a stranger tried to withdraw a few thousand dollars from a personal account).  This incident is my personal connection with the issue of security.

I’m not trying to sound like I’m paranoid or some cynic about ehealth and maintaining electronic records of our information.  I actually believe that we need to make more of our health information available in electronic format.  But, we need to be more vigilant about securing our health information. (more…)

 
              Thanks to Jack Lyons for permission to use this Photo.

Not being a clinician myself, I often rely on my students and readers to make sure I don’t miss important developments. Pete Quily, an adult ADD coach, brought the issue of mental health parity to my attention. Thanks for the heads up, Pete!

What is mental health parity? This is an effort to make health insurance coverage of mental health conditions more in line with coverage of medical and surgical services.The Senate passed S. 558 unanimously on September 18, and now the House is considering H.R. 1424 . I encourage you to read about these bills. Click here for another useful description of mental health parity from the US Department of Health and Human Services. There are a number of tables that show the current status of mental health parity in the US.  This pie chart is from the SAMHSA site as well. (more…)

               Thanks to Thomas for permission to use this Photo.

One of the key unanswered questions about health information infrastructure over the past several years has been, “Do we have enough trained people to build it?” Over the past year, I’ve been privileged to have the opportunity to serve as the principal investigator of a research project sponsored by the U.S. Department of Health and Human Services (Office of the Assistant Secretary for Planning and Evaluation) to begin to address this question. This work represents the first attempt to quantify the workforce requirements for building the health information infrastructure in the U.S.A presentation summarizing the final results was given to the American Health Information Community (AHIC) Electronic Health Record work group in late September, and the complete final report has recently been posted.  Here is the Executive Summary: (more…)

            Thanks to 416style for permission to use this Photo.

It’s been widely reported that oncologists are still trying to find ways to profit from treating their patients with expensive drugs, even though Medicare has cracked down on such profits two years ago (by limiting the markups docs can charge to 6% above the cost of the drug).

Doctors can get around the limitations in reimbursement by simply offering drugs to more patients, whether or not they’ll benefit from them. (more…)

 
      Thanks to Erin O’Conner for permission to use this Photo.

The Kaiser Daily Health Policy Report recently had a piece about an effort to survey Wellpoint’s many (35 million) about their physicians in order to provide consumer-based rankings, also to include comments. All together now: “The plural of anecdote is not data.” Indeed, as one consumer group interviewed by Kaiser said, these rankings are likely to be skewed to the negative by patients who have had bad experiences. (more…)

One of the big joys of Emergency Medicine is helping patients. It’s truly enjoyable to suture a laceration, to reduce the dislocation, to give solace to the suffering (usually pain medicine, but not always, sometimes it’s a hand to hold). These are almost always patients who present with a sudden-onset problem, be it trauma or bowel-obstruction, and that’s why I’m there (and why my colleagues are there, as well). Patient faces begin with apprehension, and are often back to normal when they leave (and some leave with a satisfied look I take as the reflection of a job well done).

Then there are those patients I cannot help but let down. They come to me with vague complaints that have gone on for years, a pain they cannot describe or can describe too well, a discomfort that nags, a rash that won’t wane, a twitch that won’t stop or a balance that won’t start. They have seen specialists too numerous to mention, have tried medicines/potions and remedies that run the gamut of medical experience, they’ve done their exercises and, still, they want for a remedy.

I have finally learned that there are some patients I probably won’t be able to help medically and that it’s actually cruel to let them think otherwise. For instance, the patient with the low back pain that’s been to seven neurosurgeons (had three operations), been to the Mayo Clinic and to innumerable chiropractors, who looks at me and says “I need to get better”, what’s causing the back pain? Realistically, what can I offer that a myriad of specialists couldn’t? Oh, I’ll do the entire LBP exam, do a history looking for zebras and other horrible causes of back pain, and occasionally I’ll want to do some tests to rule out an emergency.

I used to leave the room with the generic “We’ll get you some pain medication and do some tests”, and then return to the room after some time, when the tests are back, and go through a prolonged ‘isn’t there anything you can do’ session with the patient and their family. They know there’s not, really, but I left that door open, and it’s at least partly my fault.

     Thanks to foundphotosslj for permission to use this Photo.

So now I let them down early. Yes it’s disappointing but I think it’s healthier for them (and me), in the long run. “You’ve had this for x years, you’ve seen about a dozen specialists; as a general rule, if a bunch of specialists cannot figure it out in their offices with all the studies, tests, etc. we’re unlikely to in the ER” is now my general start-of-the-letdown, and even the least reasonable from an expectations standpoint seem to get it: I’ll try, but it’s unlikely. Now the patient doesn’t spend the next hour-plus building up hopes to be dashed-yet-again. As memory serves I’ve never made the terrific diagnosis for the unfixable complaint, and it’s not for lack of trying. Some things I cannot change.

It’s disappointing for me, too. I’d much rather say ‘here’s the diagnosis, and the cure’, but it doesn’t work that way in real life. Maybe some of the letdown is for me. Okay, no maybe about it.

We’re pretty good in the ED with acute problems, less so with the chronic ones, and dismal with the ones nobody can solve. Sometimes expectation management is the best we can do, for everyone.

(General disclaimer: I do a real history, a real physical exam, and listen to my patients. I don’t prejudge anyone, and the above applies only at the very very end of the patient interaction, and not before.)

Dr. Allen
Creator of GruntDoc
Ashworth University Contributing Blogger 

*Allen earned the alias GruntDoc through is his work as a doctor in the USMC infantry and has carried the name through his current work as an Emergency Physician.  Dr. Roberts obtained his MD from Texas Tech University and is board certified in emergency medicine.  In recent years, he has become one of the most popular and respected bloggers on matters related to health care and medicine.  We’re honored to welcome Allen as a member of our contributing bloggers’ network and would like to specially thank him for the opportunity to share his knowledge, skills, and experience with our student community.  To learn more about the life and work of Dr. Allen, visit his outstanding GruntDoc blog.  Thanks Allen!  

As any policy-maker knows, catering to public opinion, ensuring the public interest, and managing costs can seem an impossible task–especially when what the public thinks it wants is at loggerheads with what it needs. But in the case of health care, there may be an opportunity to do all three at once according to a proposal in the September/October Health Affairs.

The proposal argues for cost-effectiveness analysis (CEA) “to set priorities for Medicare coverage of new or costly interventions” through a citizens’ council made up of “a cross-section of users” who can provide leadership with “well-considered social-value judgments.” This citizens’ council model is borrowed from the UK, where a group of 30 men and women advise the National Institute for Health and Clinical Excellence (NICE) on behalf of the public.

The British experience shows that there are likely to be practical complications with implementing a citizens’ council, but it’s still an idea that’s on the right track. We need to turn “cost-effectiveness” from a bad word into a public interest issue in the US.

The authors of the proposal, Dr. Marthe Gold from CUNY, Shoshanna Sofaer from Baruch College, and Taryn Siegelberg from CUNY, envision the American citizens council as being an advisor to the Medicare Evidence Development Coverage Advisory Committee. The council would advise on the criteria for CEA—in other words, how to decide whether the effectiveness of a new intervention justifies its cost, and thus warrants coverage under Medicare. Issues to be deliberated would include: How should we assess weigh factors such as a patient’s level of suffering or disadvantage, behavioral choices, and age when making a decision? How effective must a treatment be to warrant coverage? Should we give a higher priority to preventions or cures?

These are profoundly difficult questions to answer definitively, particularly for members of the general public who lack medical expertise. As the authors note, information is a major concern—the council needs to know enough to function effectively. 

Unfortunately, striking the right balance between information/education on the one hand and deliberation/ autonomy on the other has proven difficult. A 2005 study from the Open University showed that the UK citizens council has “struggled less than successfully with understanding its role…and understanding the questions set.”

The council, caught between being the voice of the people and needing to understand complex health care issues, often lacks the right mix of “knowledge base, role, authority, and the design of the social situation.” It’s not always clear where the council fits into the decision-making process, in part because the council is expected to simultaneously learn about issues and comment on them.

                   Thanks to Jim for permission to use this Photo.

Because of these difficulties, NICE pays “more attention to the process than the product [i.e. citizens’ advice] and the way in which that product would be used.” Procedure trumps output. As a result, the citizens council is sometimes relegated to “abstract core tasks”—such as issuing general declarations rather than providing substantive guidance—a pattern that incurred the wrath of patient advocates who called the council a “toothless tiger.”

Anyone who wants to understand 21st century health care faces a steep learning curve. Balancing public input with the expertise and nuance needed to provide meaningful guidance is a tricky business, and the challenge of doing so should not be underestimated.

Still, the UK citizens council has only been around since 2002, and the Open University report notes that with every installment of the council, more and more kinks are worked out. And even if public input in health priorities represents a challenge, it’s by no means a fool’s errand.

Conventional wisdom assumes—without proof, as Gold et al. note—that Americans do not want to discuss health care costs because they view cost-cutting as a synonym for quality-reduction. But the absence of CEA in the US is due more to a lack of conversation rather than to resistance.

Polling data shows that Americans are ready to talk about cost. Indeed, it’s hard to argue that cost is a non-starter when the public views it as the nation’s most important health care problem. Back in 1999, Americans thought AIDS and cancer were bigger concerns, but today it’s the cost of health care that keeps Americans up at night. The average American is just as worried about cost as is the policy wonk, making now the perfect time to institutionalize a role for the public in cost management.

Requesting public inputs while setting health priorities can begin to demolish the misconception of “more care is better care” that conflates cost-effectiveness with stinginess. By opening the insular world of cost management to public priorities, we defuse the possibility of Americans viewing CEA as a means to “cheat” them out of care.

Will it be a bumpy ride? Maybe. But if democratizing cost-effectiveness helps the US move toward smarter, more sustainable health coverage, then it’s worth the effort.

Maggie Mahar
Creator of Health Beat
Ashworth University Contributing Blogger

*Maggie Mahar is a fellow at The Century Foundation and the author of Money-Driven Medicine: The Real Reason Health Care Costs So Much (Harper/Collins 2006) and Bull! A History of the Boom, 1982–1999 (Harper/Collins, 2003), a book that Warren Buffett recommended in Berkshire Hathaway’s annual report.  We would like offer our gratitude to Maggie Mahar for granting us the opportunity to share her brilliant perspectives with the AU student community.  Visit’s Maggie’s blog, Health Beat, for some of the best healthcare analyses on the Web.

So once again I’m in the weird position of having to defend something I’m actually against. 

The latest is from John Edwards, et al. Here’s the headline: Edwards unveils plan to control drug advertising.  Read that sentence, and decide what you think the intent of the plan is.  Is he talking about controlling the colors of the ads?

Most likely, you think it’s the effect the ads have on drug prices.  “The excessive costs of prescription drugs are straining family budgets and contributing to runaway health care costs…”

Let’s temporarily grant that that this statement is true.  What is the link between advertising and prescription drug costs?  Is he saying that spending on ads increases the price of drugs?  That would be wrong, and I have to believe he knows it.

First, Pharma spends about $4b on DTC ads.  It has yearly sales of about $200b, so even if every penny spent on ads was instead used to lower the price of the drugs, no one would actually notice.  Additionally, prices of branded drugs rise about 6%/year, regardless of how much they spend on ads.

Second, we should probably define “drug prices.”  If I roll into a pharmacy with a prescription and choose to pay cash, how much will it be?  The answer, as it turns out, depends on the pharmacy.  These are retail prices, that pharmacies charge no-insurance cash payers; on average, 15% more than insurance rates. But let’s be honest here: cash payers can’t afford a lot of these medications at any price.  If you’re one of the unfortunate working poor who don’t have a prescription plan, you can’t afford the medication at full price, 20% off, even 50% off. The price is irrelevant; what matters is whether you have a prescription plan, or a doctor who can provide samples forever.

So for everyone else, “prices” really means prices to insurance companies, or Medicaid/Medicare, all who  negotiate a price that has almost nothing to do with the actual patient demand for a drug.  A  price which is considerably lower than retail.  Medicaid apparently gets a 20% discount, the VA 40%. (1) 

So DTC advertising doesn’t affect the price because the consumer isn’t paying it.  The price was set in negotiation.  Certainly the price Pharma asks from wholesalers and insurers takes into account their costs, including advertising; and more ads (hopefully) means more scripts which means higher profits. But increases in advertising don’t translate directly to higher prices, they reduce the profits.  Higher prices are the result of  negotiations between parties that are immune to the effects of advertising.  That’s the problem.  

Third: perhaps what we really mean is that DTC ads raise the overall Medicaid/Medicare expenditures because more scripts are being written that would otherwise not have been written without the DTC ads.  Well, if this is what we’re saying, we should just say this; let’s not use factually inaccurate soundbites that play to the hearts of superficial idiots. 

But if we are saying this, then the problem isn’t the prices of the drugs, it’s doctors prescribing drugs they shouldn’t be prescribing.  The solution isn’t, therefore, to reduce drug prices; in fact, that’s the opposite of what you want, because it makes it even easier for doctors to prescribe what they shouldn’t be prescribing.  The actual solution would either be to raise drug costs (bad idea), controlling doctors’ prescribing (bad idea), or giving them a medication budget they have to stay within, but preserving prescribing freedom.

It should bring us pause that even the AMA refused to recommend banning DTC ads.  If Edwards plan was specifically about protecting the patients from half-truths or seductive graphics that compel patients to request medications that they don’t need or might compromise their health, then I’m behind him 100%. I already think DTC should be banned. But like all political soundbites, this isn’t about content but about ambiance, creating a feeling that he’s all about cutting costs— that’s he’s more than Hillary. Unfortunately, empty rhetoric like this distracts us from real problems, like Iraq, Iran, wealth divergence, recession, etc.

——

1.  As a horrifying diversion into drug pricing, let’s look at Medicaid.  Medicaid, by law, will pay (to a pharmacy who dispenses the drug) a percentage of the average wholesale price, plus a dispensing fee.  Both the percentage and the dispensing fee vary from state to state, but it’s on the order of 85% of average wholesale price, and $5 dispensing fee.  On average, Medicaid pays about $61 per prescription: $14 goes to the pharmacy, $47 to Pharma.   If anyone can tell me how DTC ads affect that, I’m listening.  So pharmacies don’t make a lot on this, and it’s a far cry from the markup the pharmacy can impose on a cash payer.  And pharmacies aren’t obligated to participate in Medicaid.

In practice, wholesale price is anything Pharma says it is, including some bizarrely inflated price.  But whatever it is, I hope it is clear that it has nothing to do with ads.

And then there are the rebates. I hope you’re sitting down.

In gratitude for this excellent reimbursement, Pharma agrees to rebate Medicaid about 15% or the manufacturer’s price, plus an additional rebate every year for the amount of price increase that exceeds inflation.  In 2003, the average rebate was 31%.

There’s another rebate.  Many insurances have pharmacy business managers (PBMs) who make preferred drug lists.  How does a drug get on that list?  It isn’t by being cheap; ask Illinois Medicaid in 2005, when they wouldn’t cover Seroquel, arguably the most demanded but hardly the most expensive.  What it takes is, as they say in Big Pharma, “our willingness to play ball.”  Another “rebate.”That money stays in the managed Medicaid’s pocket. The savings aren’t passed on to the patient, either directly or indirectly.   If you want an analogy, it’s the parking authority; revenue from tickets doubles, triples, but the amount they pay to the cities doesn’t change.   The extra “profits” goes back into the authority, to hire more people, pay more salaries. It’s a self-propagating bureaucracy.  I should also mention that, consistent with bureaucracies, it can’t even collect those rebates very well.

The Last Psychiatrist
Ashworth University Contributing Blogger

*”The Last Psychiatrist” is an academic psychiatrist specializing in forensics, a respected author, and an award winning blogger.  Selected as one of the “Best Doctors In America”, The Last Psychiatrist prefers to remain anonymous in cyberspace and allow his/her work speak for itself through their acclaimed blog.  We would like to express our gratitude to this very talented professional for providing us with the opportunity to share his/her exemplary work with the Ashworth University  student community.  We encourage you to visit The Last Psychiatrist blog for additional insights.  Thanks Doc!