Sunday, November 17, 2019

Should the price of drugs be based on what pharmaceutical companies can get or what people can afford?



The high cost of prescription drugs is an issue that seems to engage most people, including politicians both Democratic and Republican, left and right. The Speaker of the House of Representatives, Nancy Pelosi (D-CA), has proposed a bill (called, in fact, the Lower Drug Costs Now bill) that would control drug prices, at least for essential medication, a proposal endorsed by the Editorial Board of the New York Times. The President of the United States, Donald Trump, who disagrees with Ms. Pelosi on almost everything else (and indeed is in the process of being impeached by the House of Representatives over which she presides) is telling Americans that they will be able to buy their drugs, at lower prices, from abroad. Indeed, the President has gone even further, announcing that he will require health providers to post their actual prices, that is what insurers actually pay, not posted un-discounted prices, on line.



Both of those White House proposals would be terrific. They would not, by a long shot, solve the problems afflicting Americans in the arena of their health and health care – after all, posting the prices is not the same as making them affordable – but it would sure help. I have previously told the story of an outpatient hernia operation I had some years back. I left home at about 6am and was back there in my own bed by noon. Then I received the hospital bill – not including the charges from the doctors, the surgeon and anesthesiologist – for $10,000! I then got a notice from my insurer that I would have to pay $400, they would pay $1600, and the hospital would make a “contractual adjustment” for the rest. That is, the hospital, based on a contract with my insurer, would write off $8000. Whew. I only had to pay $400. But the thing is – the official hospital charge was $10,000. If I didn’t have insurance, I not only wouldn’t have been billed only $400, I wouldn’t have even been billed the $2000 that was the total the hospital collected from me and the insurance company; I would have been billed $10,000! This is absurd, and while requiring hospitals to post the prices they are actually paid by the insurance companies would not necessarily change this, it would bring the flagrant abuse of uninsured people out into the open. If you doubt the significance of this, note the objections of the hospital industry: ‘“This rule will introduce widespread confusion, accelerate anticompetitive behavior among health insurers, and stymie innovations,” the American Hospital Association and three other major hospital groups said in a statement.’ Yup, they hate it so it must be a good thing!



But back to drug prices. They are currently unconscionable. Americans pay a lot more for most drugs that they need than people in other countries. The main reason is that other countries regulate drug prices, and the US doesn’t. Indeed, when the Medicare Drug Plan (Part D) was passed by Congress during the GW Bush administration, it specifically forbade Medicare from using its clout as the nation’s largest insurer to negotiate drug prices. That was a win-win for the drug companies (The government requires every Medicare recipient to buy drug insurance and forbids it from doing anything but pay full price.) So, frankly, the White House proposal to allow American to buy drugs abroad is a minor step – nothing like actually regulating prices for drugs or even allowing Medicare to negotiate those prices for its recipients – but it is something. I support it as far as it goes. I also support Nancy Pelosi’s more extensive intervention.



There is reason, however, to be skeptical of whether the White House will actually implement these changes. Impeachment aside, promising things that he cannot or will not deliver on is the routine modus operandi of President Trump. I hope this is the exception. Pelosi’s Democrats are, I believe more sincere in their desire to limit drug costs, but it is unlikely that a plan of theirs will pass the Senate, and if it should, the President would likely veto it because it is not his plan. And, of course, it might hurt the drug companies; he likes to use them as whipping boys, but they are a big part of the huge corporate complex that has benefited from all of the Republican’s policies, and contribute a lot. They also contribute a lot to Democrats.



Sometimes in discussions about drug prices, similar to discussions about other situations that lead to enormous industry profits, we hear arguments that include the need for research and development on new drugs and the possibility that Americans do better as a result of paying more for their drugs than people in other countries who pay less for the same medicines. We also hear that since insurance companies pay for these drugs, the high cost really doesn’t hurt Americans. All of these arguments are worse than baloney – they are purposely produced propaganda funded by the pharmaceutical industry as part of their marketing budgets, in the interest of maintaining their profits. Luckily most Americans are now seeing through the smokescreen, as indicated by these proposals from both parties.




A recent study by Navindra Persaud and colleagues published in JAMA Internal Medicine[1] found that adherence to treatment was significantly higher among a group that received their drugs free of charge. This should surprise no one, least of all pharmaceutical companies. (The fact that only some disease outcomes improved may have more to do with how well these drugs actually are effective in doing what they are supposed to do.) The idea that lowering prices would inhibit access to medicines is belied by the fact that drug companies make plenty even with lower prices or they wouldn’t sell their drugs abroad.
So reducing drug prices and thus limiting the exorbitant profits made by the pharmaceutical industry is important. The cost of those drugs eats into the ability of Americans to pay for other things – not just luxuries, but also food and rent. And, as always, while it can affect most of us, the impact is greatest on those with the lowest income. It may happen, although the corporate ownership of both the mainstream Democratic as well as Republican parties will be a big obstacle.



But we need more than just lower drug prices, and certainly more than the ability to purchase drugs abroad. We need to have comprehensive health system reform that provides coverage and access for all health care for all people at affordable cost to them. This means cutting the income and profits of not only pharmaceutical companies but insurance companies and – absolutely not to be missed – health systems. After all, a recent article in the Mayo Clinic Proceedings describing the major individuals with an influence on health policy indicated that

there were 1700 persons named from 2002 to 2018, a minority of them women (range over the period, 17% to 28%). Most influencers are top executives from nonprofit health care provider organizations; their proportion has increased from 23% in 2002 to 72% in 2018, with an apparent substantial upward inflection in this trend since 2009. This predominance appears to be at the expense of academics, advocates, and government officials.



 The objection that we cannot take on too much all at once is specious; it is only by taking on everything more-or-less simultaneously (or in quick succession) that we can prevent gaming of the system and actually improve health care for all Americans.






[1]  Persaud, N, et al.,  Effect on Treatment Adherence of Distributing Essential Medicines at No Charge: The CLEAN Meds Randomized Clinical Trial, JAMA Intern Med. doi:10.1001/jamainternmed.2019.4472

Published online October 7, 2019.

Sunday, November 3, 2019

Reimagining healthcare: How about imagining if everyone could get it?


Several years ago, the University of Arizona Hospital was acquired by Banner Health, a large not-for-profit system with no previous presence in Tucson. Banner now employs the physicians for their clinical time. This arrangement is not unusual among academic health centers. An advertising campaign has been in place for several months which I hear mostly on the local NPR outlet, indicating that Banner and the University have joined together in a commitment to “reimagine healthcare”. I keep trying to imagine what this means, since, in itself, “reimagining healthcare” is at best meaningless and at worst ridiculous. It is clearly an advertising message, a slogan obviously thought up by a marketing firm (or possibly an employee in marketing), that is intended to grip the pubic, make them think that Banner/UA is doing great things, and, hopefully, abandon their current healthcare providers and rush over to where healthcare is being reimagined. I have no idea if it works; I guess the future will let us know if they continue with this tagline/slogan or come up with a new one. But I am deeply offended and upset that they are using this sort of content-free marketing tactic. Indeed, any marketing tactic, although I guess when they tout their excellence in specific services, there is at least content.


First, however, let me make clear that this is not particularly about Banner/UA, or meant to single them out as an egregious abuser of advertising slogans. I cite them because I live here in Tucson and hear it on the radio. I am sure that if I lived in another city, with another large health system, in collaboration with an academic medical center or not, I would hear similar ads. It is not just the specific ad, in all its vague and substanceless inanity, that is galling; it is the fact that there is marketing of healthcare services to the public as if it were make of car or brand of cereal. We are talking about healthcare, about people’s lives. The goal of a nation’s healthcare system should be solely to bring the greatest health possible to the most people. It should not be to market one system’s health services instead of another, Ipana® vs Gleem®, Bristol-Myers vs. Procter and Gamble. At least Bucky Beaver had big teeth, so somehow relevant to toothpaste (choosing those brands is just a nostalgia shoutout).


If there is a perfectly good cancer center/heart center/neurosciences center at one hospital in town, it makes no public health sense to build another and then advertise for it (Newer! Improved!) to draw people away from the first. It would make sense, from a public health point of view, to build a psychiatric or drug treatment facility if those are lacking in the community, or to build a facility to care for the people left out of access to the existing services because they are poor, uninsured, or – and this for sure happens – have an unprofitable-to-care-for disease. Or how about, here’s an idea, to build a facility in a smaller community where people have limited or no access to health care instead of having everyone competing in the major metropolitan markets? Those things would make public health sense.


Ah, but they do not make business sense! All of the things I have just cited as bad -- competing health systems and facilities in major marketplaces resulting in oversupply of some services, marketing to try to get people to come to your place instead of the other one – make perfect sense in a for-profit competitive business. And the things I said we need – provision of services that are currently in inadequate supply, provision of care to people who cannot access it, development of services for conditions with great need but generating little income, provision of services in less densely populated areas -- make little business sense. They are more likely to lose money than to make it – or certainly make less than something else the corporation could invest in. (I often find myself mis-typing “copro-ration”; maybe it is a Freudian slip?*)


The question is why we, as a society, allow healthcare to be a business, either directly for-profit or ostensibly not-for-profit (as most big health systems including academic health centers are) but operating by the same business principles (thus being essentially for-profits that don’t pay taxes, being the worst of both worlds!)? It is not the same as Ipana® vs Gleem®, or in current terms Crest® vs Aim®. It is not the same as Dodge vs Ford, or Burger King vs McDonalds, or Cheerios vs Kellogg’s Corn Flakes (or Cocoa Krispies vs. Count Chocula)! It is about your, and your family’s and friends’, health and lives. We accept it because some of us get, or think we will get if we need it, all the health care we need, and more. And this includes all the politicians, and pundits, and frankly news media – almost everyone in the upper- and upper-middle class. And the people who own stock in for-profits. And the politicians who benefit from the contributions of the non-profit as well as for-profit health care sector, and the power they wield as major employers in town. 

Of course, some of them will be surprised when they get sick, too. The people who can’t get care because they have no money or insurance, or crappy insurance, or have diseases the care for which are not well reimbursed, or maybe are just not our target market (let’s put our sports medicine clinic in the suburbs, and for goodness sake discourage old people with arthritis from coming in, we want the high school quarterback and his parents!). There are, of course, people who benefit. Rich people. Private equity companies and their investors, as described in the article by Gustafson, Seervai, and Blumenthal in “The Role of Private Equity in Driving up Health Care Prices”, in the Harvard Business Review.
 

It does not have to be this way. It is not this way in most countries, including most capitalist countries. (see, because I like it, One thing to NOT worry about: paying for health care -- in France, July 21, 2012).Those countries realize that the health of people is not a market commodity, but is a public service like roads and police and fire departments.


Maybe we’ll make the fire department for profit. Or the police. And they’ll only come if you have not only insurance, but the right kind of insurance, and have met your deductible (of course, in some neighborhoods it is kind of like that already…)


Or maybe, better yet, we can realize that our health is not something that should be dependent on a corporation making a profit.

*https://www.dictionary.com/browse/copro-

Thursday, October 24, 2019

Expecting everything from primary care: reasonable?


In 2003, Kimberly Yarnall and colleagues from Duke University published an article in the American Journal of Public Health documenting that it would take 7.4 hours a day, essentially an entire workday, for a primary care physician to perform all the preventive services recommended by the US Preventive Services Task Force (USPSTF) on a typical population of 2500 patients.[i]  Six years later, they wrote a follow-up article in which they added the time it would take to also deliver care for the acute and chronic conditions that patients actually came to their doctor for, and it came to 21.7 hours of a 24-hour day![ii] One year after that, in What’s Keeping Us So Busy in Primary Care? A Snapshot from One Practice, Richard Baron wrote about a day in his practice, where, in addition to seeing an average of 18.1 patient visits per day (the one activity they were paid for), they also returned an average of 23.7 telephone calls, and 16.8 email messages. They refilled 12.1 prescriptions, reviewed 19.5 laboratory reports, 11.1 imaging reports and 13.9 consultation reports per day, and also filled out large amounts of paperwork that they do not report on because they are not captured by their electronic medical record, such as “…administrative forms (e.g., for physical examinations for work, camp, and school and Family Medical Leave Act forms), correspondence received from health plan (e.g., disease-management letters), and reports on home care and physical therapy.”[iii]


When I wrote about this, in Primary Care: What takes so much time? And how are we paying for it? (May 21, 2010), I discussed the incredible burden that this placed on primary care physicians, and how unrealistic it was to expect this of them. I addressed an article by David Margolius and Thomas Bodenheimer, Transforming Primary Care: From Past Practice To The Practice Of The Future,[iv] in which they envision the effective and efficient provision of primary care by well-designed teams. I also expressed some skepticism about how likely this would be to happen. So, now it is another 9+ years since the Baron article, and how far have we come? Not, as it turns out, all that far. The impetus in medicine, from health systems, payers, and primary care physicians’ own specialty colleagues, is for more and more work to be expected from primary care providers, both in terms of direct patient care (acute, chronic and preventive) and the kind of paperwork and form-filling-out described by Baron. This comes, unsurprisingly, with little additional financial reimbursement to the doctors or practice (or financial support from health systems for the kind of expanded teams envisioned by Margolius and Bodenheimer), and certainly without more hours in the day!


Why? For one thing, it’s easier. If you don’t know where something fits in the always-getting-more-complex-and-confusing health system, assign it to primary care providers. This is particularly attractive if you are a specialist and it’s something you don’t want to do. And, if you are a health system manager, if it is something that is poorly reimbursed. Think about it. The surgical subspecialist, for example, wants to operate on people. S/he wants, perhaps, to consult with patients about their particular problem, and maybe even their concerns about it, but mostly wants to operate, and to generate the income that comes from operating and not to fill their time up with additional paperwork, or blood pressure checks, or FMLA requests. When they do follow-up they mainly want to follow up the narrowly-defined surgical problem; if there are other complications that are acute, there are consultants for that; if there are longer-term issues that will need to be dealt with, there are primary care providers for that.


Similarly, the health system makes money from procedures being done, and wants their proceduralists, say this subspecialty surgeon, to generate the surgical procedures that make them money, not “waste their time” on more poorly reimbursed medical activities -- or certainly paperwork. When such work can be done by others – nurse practitioners or physician’s assistants, or scribes or nurses, or anyone who gets paid less, then it is financially efficient to fund those positions. In her New York Times article “The Business of Health Care Depends on Exploiting Doctors and Nurses” (June 8, 2019), Danielle Ofri, a physician at Bellevue Hospital in New York, makes a truly important point: that health care professionals actually care about their patients, and want to do the right thing, and will work hard even when that requires more hours than they have or are being paid for. In this sense, it is the health systems (individually) and the health system (writ large) that is profiting. But it is also true that the degree of exploitation (and payment) is not the same for all health professionals; it is not the same for nurses and doctors, and it is not the same for primary care doctors and many subspecialists.


Primary care physicians may inadvertently encourage this. As Ofri describes, they want to be professional and responsible, to know about everything that is going on with their patients. They want to be the physician for the patient, not the disease, to coordinate and manage all the care, to interpret for their patients what other doctors are telling them, especially when the messages that the patients are getting are mixed or unclear. This is what makes them good doctors. However, it is also what makes them really good candidates for being the “buck-stops-here” venue, the “take care of everything no one else can or wants to”, especially if these tasks, from the larger health system point of view, are not reimbursed or poorly reimbursed in themselves but are required by payers (private and government insurers) to be done in order for the system to get reimbursed for the high-ticket items (such as surgery) that they provide.


This is not irrational. It makes sense for people to do the work that only they can do, to, in the jargon, “work at the top of their license". But this requires changes in reimbursement. In particular, the concept that a single episode of treatment (e.g., surgery) is worth a lot more than the ongoing continuous lifelong management of a person’s health needs to be re-examined. But for this to work, adequate resources – especially human, like enough primary care doctors so that they don’t have the 2500 patients each, and enough support nurses and assistants and clerks and scribes to address the workload – have to be available.


Some primary care providers have moved into “direct primary care”, where, for a fee beyond insurance reimbursement, they provide (presumably) all the primary care needs of smaller group of patients. It has its pluses, but without adequate numbers of providers and without a national health insurance system covering everyone, it leaves too many people out; it becomes another “market niche” for those who can afford it, and this is not what health care should be.


I have heard it said that there are 3 entities that are always identified as likely places when something additional is suggested to be added to health care: primary care, nursing education, and black churches. Nursing education because, you know, nurses should know how to do that (whatever that is today). Black churches, you know, because they are important institutions in the community, with credibility, so if they urge people to healthier behaviors it may work better than when outside health professionals do. Could be a good idea. Maybe the nursing schools or black churches could hire people who could use the jobs to do this work.


But, as in primary care, rarely are these “good ideas” backed up with money, with sufficient funding to make it happen, to employ people, to support them. That money, of course, needs to go to for health systems, subspecialists, insurance companies, and mega-corporations.


Time for a change.





[i] Yarnall KSH, Pollak KI, Østbye T, Krause KM, Michener JL, Primary Care: Is There Enough Time for Prevention?

MD Am J Public Health. 2003 April; 93(4): 635–641.PMCID: PMC1447803. PMID: 12660210

[ii] Yarnall KSH, Østbye T, Krause KM, Pollak KI, Gradison M, Michener JL, Family Physicians as Team Leaders: ‘Time’ to Share the Care, Prev Chronic Disease Apr2009;6(2):A59),

[iii] Baron R, What’s Keeping Us So Busy in Primary Care? A Snapshot from One Practice, New England Journal of Medicine, Apr29,2010;362(17):1632-6


[iv] Margolius D, Bodenheimer T, Transforming Primary Care: From Past Practice To The Practice Of The Future, Health Affairs May 2010, 29(5): 779–784.

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