Thursday, February 21, 2019
Blog Page 1032

PBMs: These are the good-old days for the PBMs

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Caremark’s (and AdvancePCS) stock jumped today because (as expected) the FTC has approved their merger. Both these stocks are at significant all time highs (or at least Caremark is up 8-fold since it got out of the physician business in 1997-8, and AdvancePCS is 50% above its high of 2001 and nearly 40% above where it was immediately after when the merger’s announcement last September).

The market has drunk the kool-aid (and likes it!) regarding the conversion of the AdvancePCS lives to mail-order (to increase margins) and the big opportunities in the Medicare PDIMA drug coverage market.  No-one seems to be paying any attention to the various court cases in this market, or the inability of PBMs to control drug costs.  My suspicion is that the PBMs will find the next few years to be fairly heavy sledding as they get ready for Medicare drug coverage, and the stocks will react accordingly–it’s tough to maintain P/E ratios in the high 20s and low 30s in the health care insurance business (United’s is 20 and Wellpoint’s is 17). Even Medco, which beat profit forecasts this morning but has since sold well off its early highs, has a P-E only in the low 20s. Where the top for the sector is exactly, I don’t know, but I think it’s sometime this year.

Unless of course PBMs can really innovate in health management and reap some rewards from that, which I doubt (but they don’t) and get someone else to pay them for it.

QUALITY QUICKIE: Prescribing wrong drugs happens too often

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A CDC study shows that one prescription in every twelve written for elderly patients is potentially dangerous. The full abstract is here while here’s the rather more user-friendly news release.  What’s somewheat depressing is that this is 2000 data and despite the IOM report and other news about, nothing had improved since 1995.  Hopefull it’ll be better by the time the study is done in 2005, with more attention to the issue and more electronic prescribing.

HOSPITALS: Is HCA having a Tenet-like moment?

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From the TCHB Sacramento bureau, Matt Quinn has some comments on a HCA hospital that is on the verge of losing Medicare reimbursement status due to violations of the Medicare safety regs. Matt writes:

    Is HCA the next Tenet (hasn’t it already been one?)?  Tenet – allegedly -didn’t have the systems and processes in place to notice  that its cardiologists in Redding were doing 10+ times the level of procedures of other hospitals in the country.  It is scary to think that HCA is similarly missing the compliance monitoring systems and processes that would make it totally unaware of serious deficiencies in three major areas – nursing services, emergency services and patients’ rights.  Or perhaps (like HealthSouth) they were intentionally filling staff spots with the wrong folks in an effort to save a buck, make more revenue at a lower cost and deceive themselves on internal reporting efforts.  It’s kind of like in the Army when supply and personnel clerks are "battle rostered" into combat engineer squads for reporting (but not training) purposes; the numbers look good on paper (i.e. squads have their full complement of soldiers) until someone (periodically) blows the whistle on the whole charade and demands to see the real numbers.  It usually takes an outside (GAO-type) agency to do this because everyone in the succession of command has an interest in everything appearing "good" under them (i.e. the BDE commander will appear to be deficient if one of his BNs has personnel problems; the DIV CDR appears to be deficient if one of his BDEs has problems, etc.).  In other words, either reporting the true numbers or calling "BS" on someone under you reporting bad numbers is career suicide.  I wonder if similar careerism is at hand at HCA.  Or if they’re just negligent or greedy?

Extra points for you non-military types if you actually know what a BDE is, but the problems Matt’s hinting at were there at at Tenet, Healthsouth and of course HCA when it was called Columbia/HCA and when "health care never worked like that before".  I’ve posted before on why Wall Street hates health care services but doesn’t know it

However, in the short term Tenet’s stock looks close to a bottom to me, as there can’t be much more bad news, can there? (Full disclosure: I’ve bought some for a short-term play).

PHARMA: Business, Science Clash at Medical Journal

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The Washington Post reports on a story about the journal Dialysis & Transplantation allegedly pulling an article critical of the use of the drug Epogen.  Apparently the commercial staff over-ruled the editor, fearful that the negative article might cost them future advertising revenue.  This all strikes me as very strange.  Amgen (who make Epogen) certainly don’t want the publicity this generates as it implies it’s their fault.  And for that matter, even if the article was published, would Amgen really stop advertising in one of the main journals aimed at its core prescribing specialists? There is indeed cause for concern about the relationship between academia, medicine, journals and pharma companies.  But this seems to be a storm in a tea-cup, or a case of one magazine unnecessarily self-censoring. 

On the other hand maybe the author of the offending article welcomed the free publicity. It’s not exactly new to suggest that new uses for drugs (in this case higher doses of Epogen) sometimes have undesirable effects.  And pharma companies spin the results while they can, but generally in these niche cases (even though there are a fair few of them), the medical science will get a good hearing before the payers will pay up.

TECHNOLOGY: XML as another savior for clinical computing?

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Robert Mittman has another iHealthbeat technology column, this time on the progress in health care of XML. It’s well worth a read. Particularly interesting is the suggestion that, by formatting all those transcribed dictated notes which are currently in word documents (and then printed out on paper and sometimes stuck in the chart), in XML, a physician will be able to search for and find previous notes.  They’ll also be able to search across an "on-the-fly" meta database of all patients in the institution.  This is probably some years away, but XML may just be the answer to the challenge of getting the clinical note into a machine in a format where it can be recovered usefully, without making the physician do anything different in their current workflow.

HOSPITALS: Emergency rooms suffering from crowding, non-emergent patients and losing specialty coverage

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The Schumacher Group is out with a pretty interesting survey on emergency room issues, with implications for hospitals and payers in a couple of areas.  It says basically that:
— for most emergency rooms a lack of specialists both on call and for follow up care is a problem. This is leading to diversions to other ERs.  The  lack of interest from specialists in working on call in ERs is driven by fears of malpractice liability, and a lack of professional compensation for non-insured patients. Competition between hospitals for these specialists is also causing problems.
–significant amounts of non-emergent patients are showing up (nearly half of all patients in more than 50% of all EDs!)
–overcrowding is the single biggest problem in ERs

This survey essentially confirms that the ER has become the de facto primary care service for far too many people. Until we develop a universal insurance system with some kind of proper access to real primary care, we will continue to waste scarce resources.  Equally badly, those hospitals that can get away with it will close their ERs, making life all the more dangerous for all of us the next time we really need one. You don’t hear too much about this issue any more, which is a pity because it’s one of the few aspects of our health system where the mess we’re in can seriously affect even the wealthiest among us, and so there might be a willing coalition developed to fix it.

TECHNOLOGY: PDA use by pediatricians

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In an article in Pediatrics Carroll and Christakis report that 35% of pediatricians use a PDA at work. So for that 35%, what do they actually do with them?   80% use it for a drug reference and 65% for scheduling but as this chart shows only 22% kept patient information on the PDA and few wrote scripts (8%) or used it for billing (4%). So, as I surmised in my earlier piece on PDA use, the tools are out there, but they are not integrated into the wider clinical workflow.  Integrating these tools which are entering via the "backdoor" into the overall clinical workplace IT strategy is the challenge for CIOs.

POLICY/EMPLOYERS: All you need to know about health care is in this article

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Everything you ever wanted to know about the US system is buried in this article in the NY times article called Whose Problem Is Health Care?. The interesting core paragraphs tell you that

    After corporate income taxes, employee benefits are the second-largest structural cost for American manufacturers, adding 5.8 percent to costs, according to the study. In all major economies, paying for health care means a combination of public and private money. But in the United States, businesses pay a larger chunk than do their European and Asian counterparts.

    "In Canada, for example, a lot of the expenditures for health are funded out of general revenues," said Jeremy Leonard, an economic consultant for the Manufacturers Alliance, and the report’s main author. In Canada, the private sector spends 2.8 percent of gross domestic product on health care; in the United States, the private-sector figure is 7.7 percent. And American private-sector spending falls disproportionately on big employers like manufacturers. Some 97 percent of members of the National Association of Manufacturers provide health care coverage for employees. In 2002 alone, General Motors, which covers 1.2 million Americans, spent $4.5 billion on health care.

    Uwe Reinhardt, an economist at Princeton, has referred to General Motors, Ford and Daimler-Chrysler as "a social insurance system that sells cars to finance itself.”

And as Uwe knows, the US government is a mutual insurance company with large military wing struggling with its debt repayment package.

All the other salient facts are that over 95% of companies with more than 200 workers provide health insurance, and only 65% of those under 200 employees do.  And those that do not are the ones paying low wages (i.e. it’s not the law firms or boutique investment banks). So that’s where uninsurance comes from and why 85% of the unisured are the working poor.

The other side of the story is that the US private sector spends 7.7% of GDP on health care. (I think that’s the same as saying that of the GDP, 7.7% goes on health care that is privately funded).  If I recall it rightly some 15% of private sector payroll goes on health care costs. But the overall issue is that although costs are a big deal for employers, they are not the biggest deal and are a realtive low percentage of total expenditures. Contrast that with the role of the health minister in most European countries.  His or her health care bottom line is 100% of what s/he cares about, and also has to be defended from both other government departments and the central treasury in governments that budget centrally, not at the whim of a parliament that can create programs without caring about the overall government budget (as does the US Congress). Hence, no-one in the US is responsible for overall health care costs.

This is not in itself good or bad.  It’s just different, and certain parties, such as large employers, the uninsured and anyone buying their own health insurance, do way worse than they would in a system that didn’t rely on employment-based insurance and had some central cost control.  But don’t worry, if you’re reading this and you don’t fit into that category–perhaps because you work in the health system–it probably means that you’re doing better than you would in one of those nasty single payer countries!

GENERAL: Monday morning grab-bag

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I’ll be back tomorrow (hopefully) with some interesting stuff about the argument around drug prices, but for now, here’s a varied few shorts that you can look at.

TECHNOLOGY: Physician to patient communication online continues to make slow but visible progress.  Pioneer Relay Health (the former  Healinx) continues to make sales (requires free reg).

INDUSTRY/POLICY: Harris Interactive has an interesting survey taken amongst the audience of the latest mover and shaker health conference in Washington (the Global Health Congress). The consensus is (drumroll please)
–health spending will go up fast
–uninsurance will go up to 18% and the rate of employer-based insurance will go down
–drug price differentials between the US and Europe will erode in the next 10 years
–more for-profit hospitals (as a share of all hospitals)
–more for-profit insurers (as a share of all insurers)
and by far the most significant  opportunity will be the adoption of information technology

INDUSTRY: There are fears that specialty hospitals will gut community hospitals leading to a death spiral in the non-profit sector (with consequent negative impacts on charity care for the poor).  That lead to the moratorium on new specialty hospitals in the recent Medicare bill.  But the news from that upstart sector suggests that things might not be going so well there.  MedCath, the largest player in the specialty heart-hospital lost money last quarter because of a rise in the use and price of drug-eluting stents and other expensive supplies.

HEALTH PLANS:  You know that I’m a little bearish on health plans.  While the sectors stock average is still relatively stable, Cigna had a very bad day at the office on Friday.  Despite the fact that it beat earnings expectations, Wall Street hated the fact that it’s losing enrollment at a fast rate, and looks to be losing more.  It also took a charge to lay off over 3,000 employees.  The stock tanked nearly 10%. By the way, I’ve been hunting for a stock index for the health plan sector.  Anybody know of one? Please email me.

TECHNOLOGY: Spending and adoption in the clinical IT market — Is the S curve getting up off the floor?

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You know that all technology diffuses in an "S" curve, and the trick is figuring out when the line goes up from snaking along the floor and starts heading up sharply–the "hockey stick" growth phase. Whisper it quietly but in terms of health care clinical IT, we may be about to enter that state.  The Dallas Business Journal reports that interest in IT spending is on the rise amongst health care CEOs. Meanwhile, on the eRX front there are a couple of interesting developments with industry giant Mckesson getting together with Surescripts to help round out the pharmacy systems integrated into Surescripts’ ePrescribing network.  In a similar vein, small but feisty handheld vendor PatientKeeper won another contract which "gives physicians real-time access to patient lists, consultation lists, the previous three days of laboratory data (with built-in alerts for labwork of critical value or results out of normal range), and dictated radiology data." PatientKeeper is also trying to move physicians to enter and update charge-capture information, which in turn should increase their revenue. In addition to this news, quite the good day was had by Cerner, which despite going 0 for 4 in its quest to win any regional UK contracts, upped profit expectations based on increased business in the US (including its recent contract with large Catholic chain Ascension Health) and was rewarded with a 15% rise in stock price yesterday.

On the plane last night I met a senior sales exec from Allscripts.  We swapped eHealth war stories, and he told me essentially how grim life had been in the trenches trying to get some sales going in the late 90’s and early Zero’s.  Allscripts was really the only eRx vendor that was left standing and that was partly because it IPOed a little sooner than iScribe, ePhysician, Parkstone et al which never got out and all died. But in the last 18 months, things had turned around and every significant medical group he was talking to had decided to do something in the clinical/physician IT space. Allscripts after some tough times is now up to 10,000 docs at around 150 sites, and maybe one of the companies poised to actually benefit from the "S" curve take-off.

Are we really entering the two to four year hockey-stick growth phase for clinical and physician IT use?  I don’t know, but to quote Ian Morrison, "if something’s going to be a big deal it’s got to start sometime."