I’m at an IFTF meeting on the Global Health Economy. IFTF has gone a little off into left field on the “health” issue since I left. They’re slowly coming back relating “health” back to the health care system (the stuff that we care about THCB), but the meeting is about personalized health, people opting out of the health care system, “body hacking” and how companies can sell to the health market (which primarily means food!). More later…
TECH: Is Newer Better? It’s a Coin-Toss, by Maggie Mahar
Last week The Annals of Internal Medicine roiled the medical world by publishing a study suggesting that the drug-coated stents produced by companies like Boston Scientific and J&J may not be quite as miraculous as first advertised.Following a two-year study, researchers at the Cedars-Sinai Medical Center in Los Angeles are now suggesting that the “putative superiority” of drug-coated stents "is founded on questionable premises. Or as The Wall Street Journal put it, the clinical trials of drug-coated stents (mostly funded by manufacturers), may “have exaggerated their real-life advantage.
Stents, you may remember, are those tiny metal scaffolds that cardiologists use to prop arteries open after they have been cleared of fatty deposits. Since they were approved in the early 1990s, manufacturers have made a fortune peddling the devices which, they say, can prevent a future heart attack while avoiding riskier and more invasive bypass surgery Today, stents are used in 85% of all coronary interventions in the United States.
Before turning to the new Cedars Sinai study, it should be said that THCB has long harbored doubts as to whether these cunning devices represented the best solution for quite so many patients. Back in 2003, THCB quoted a Stanford study which suggested that, over the long term, patients with multi-vessel disease would achieve better outcomes, at a lower cost, if they opted for the bypass.In 2005 THCB questioned the cost-effectiveness of the new, improved “drug-coated” stents that are designed to prevent the growth of scar tissue inside the artery. Granted, the drug coating has a real advantage: without it, scar tissue can cause the artery to narrow again. And while there is no proof that the coated stent improves survival (the scaring rarely leads to deaths from heart attack), scarring can affect a patient’s quality of life by causing chest pain. And ultimately, he or she may need to have the area opened up again.
Thus, drug-coated stents have become wildly popular, thanks in part to what The Annals of Internal Medicine describes as “aggressive marketing” and the unbridled expectations of patients Wall Street likes them too. At $2300 a pop (vs. a mere $700 for the uncoated, bare-metal variety), the newer stents are far more profitable. Despite the hoopla, nine months ago THCB was once again forced to ask “Are Stents A Waste of Money?” after reading about a study of 826 patients, published in Lancet, which suggested that the drug-coated stents made by J&J and Boston Scientific aren’t cost-effective for all patients and should be restricted to those at highest risk for heart attack.
A second 2005 study, published in The New England Journal of Medicine, added to the uncertainty about the widespread use of stents by reporting that patients suffering minor heart attacks do equally well with drug therapy. "In a study colliding with established practice, recovery from small heart attacks went just as well when doctors gave cardiac drugs time to work as when they favored quick, vessel-clearing procedures,” the NEJM reported. "The surprising Dutch finding raises questions over how to handle the estimated 1.5 million Americans annually who have small heart attacks – the most common kind. Most previous studies support the aggressive, surgical approach. ‘I think both strategies are more or less equivalent. I think it is more a matter of patient preference, doctor preference, logistics and, in the long run, it could be a matter of cost,’ said the Dutch study’s lead researcher, Dr. Robbert J. de Winter of the University Amsterdam."
Against that background, it should come as no surprise that the newest study published in the Annals last week is making hospitals think twice about using coated stents.
OFF-TOPIC: World Cup medical latest
So the main Aussie star, Harry Kewell, couldn’t play against Italy because of gout. Being a fellow traveler I sympathize, but isn’t he a bit young and thin for that?
POLICY: The times they are a changin’?
By THOMAS R.LEITH
I am not quite sure what to make of this. In this past Sunday’s (18-Jun-2006) edition of the St. Louis (my fair city) Post Dispatch on Page 1, above the fold, was a story headlined Is your doctor paid to keep you healthy? Probably Not.
Typically, physicians get paid only when their patients receive care, and more complex care often brings bigger paychecks. At the same time, doctors complain that paltry payments for office visits force them to rush through checkups instead of educating patients about their illnesses, medications and healthy living – all of which might lower future medical bills.
It’s a system that gives doctors little financial incentive to keep patients well. And, experts say, it might be contributing to dangerous, unnecessary care as well as high medical bills.
So, the writer (Mary Jo Feldstein) has got the problem identified. Good. The rest of the story is about three things:
- Medicare Advantage (“like” an HMO)
- Disease Management & Care Coordination
- Essence, a Medicare Advantage plan owned by a big medical group here in St. Louis
The article speaks glowingly about “better quality at a lower cost”, acknowledges in passing that Medicare Advantage beneficiaries all go to doctors chosen by the plan, but then (get this) does not dwell on the restriction of “choice”. This is uncharacteristic of this newspaper. Wow. Oh, and Maggie Mahar’s book gets yet another plug in the article. I thought she’d like to know that.Then on the front page of today’s (22-Jun-2006) WSJ, above the fold is a story (sub req’d) about how the New York State Medicaid department has discovered Disease Management. In a deal struck between the state and Mount Sinai Hospital, their outpatient clinics were designated “Diagnostic and Treatment Centers” which brought higher Medicaid reimbursements. In return Mount Sinai runs a DM program around CHF, and the state’s total Medicaid payments to Mount Sinai Hospital have fallen. But this is evidently OK with the hospital: they have been running at 95% capacity, and would much rather have a bed filled by (say) a commercially-insured ortho patient than by a Medicaid CHF patient. Evidently things are working as expected. The government of New York State has begun to pay docs to keep patients — OK, they’re not healthy. Healthier. Or at least out of the hospital and more functional.So? With attitudes towards the loss of “choice” changing evidently among patients and (significantly) the press, and with a new apparent willingness to pay doctors and allied pros to think and talk to and teach patients, maybe — just maybe the stage is being set for a resurgence of `70s idealistic Managed Care Organizations. Toss in a handful of transparency, shake it up a bit, let it marinate a few years and it could be we have an environment where the Enthoven Plan doesn’t look so revolutionary. Or scary.
TECH/QUALITY: Buying Guidant still such a great idea?
“We knew, when we did our due diligence, that the [cardiac rhythm management business] of Guidant hadn’t had its last recall,” Chief Executive Jim Tobin said on a conference call with analysts and investors. He said it will take 18 months to 2 years to resolve all of the issues related to the acquisition.
So that’s what the CEO says but the market doesn’t really believe him. As it is Boston Scientific stock is down about 6% on the latest recall of a Guidant device. And that’s before the real story of the future of the Drug Eluting Stent gets out. (More on that arriving at THCB any day now).
TECH: Barcoding prevalent almost everywhere! (Just kidding)
Brian Klepper writes to tell me that in today’s almanac
On this day in 1974, bar codes were first used in supermarket checkout lanes. In a Marsh’s supermarket in Troy, Ohio, the first product to be scanned was a 10-pack of Wrigley’s Juicy Fruit chewing gum. It just happened to be the first thing lifted from the cart. Today, the pack of gum is on display at the Smithsonian National Museum of American History in Washington, D.C.
Of course bar coding is used uniformly in every health care establishment now, so why would the fact that retail’s been using bar-coding for 32 years be on this blog? Oh, hang on a minute….
OFF-TOPIC: Torture day 2006
Today is Torture day 2006. That’s not an invitation for people to do more of it despite what our current Adminstration thinks. instead it’s UN International Day in Support of Victims of Torture. I’ve supported a London Charity called The Medical Foundation for the Care of Victims of Torture for years, and I invite you to check out their web site. Whatever your political views this is an organization that but for the accident of birth we might all need.
HOSPITALS/QUALITY: A quiet little speech by Michael Millenson
Millenson on the lack of real committment to patient safety. Acerbic and fantastic. A few quotes, but as they say in the blogosphere read the whole thing
If there is a quality crisis today, it certainly is not apparent from the actions of major stakeholders….
…on the fifth anniversary of the IOM report, the Institute for Healthcare Improvement launched its "Save 100,000 Lives Campaign." It is a wonderful campaign, even if four out of every 10 hospitals don’t participate. What does that say about the will to change?
…Imagine what might happen in the QI world if the head of the IOM publicly criticized by name those 40 percent of hospitals that declined to participate in the IHI safety initiative. Imagine if Congress reacted by holding hearings. Imagine if CMS asked the Joint Commission to investigate whether those hospitals were really as safe as they seemed to think they were. Imagine if there were class-action lawsuits filed. Imagine the impact this unprecedented kind of focused, multi-faceted pressure would have on the "will to change" and the cultural context of quality improvement. If you find this scenario unlikely, it may be because those promoting the quality agenda sometimes seem to display greater concern for those whose behavior they are trying to change than for those whom that behavior is hurting.
POLICY: Universal Health Care in San Francisco…well not exactly
My buddy Laura Locke has a nice article in Time about San Francisco’s Latest Innovation: Universal Health Care. This one’s closer to the George Bush agenda than gay marriage—and I’m pretty sure that we’ll all have accepted gay marriage long before we’ve got to genuine universal health insurance. Essentially it’s about redirecting funds from the City and County back to the city and county health facilities, and making the uninsured pay into a pool. Not a bad start given that a City can’t do much, but it’ll run into trouble, just as I explained a while back when the proposal first came out because it’ll mean small low-wage businesses will have to pay more.
PHARMA/POLICY: Scottish Drug Czar Says Drug War Is Lost, Causes Big To-Do
Everyone with half a brain knows that the drug “war” is lost and was always unwinnable and that the drug “problem” is only controllable by sensible legalization, regulation and education—as has been done with other addictive drugs like alcohol and tobacco. But it’s pretty rare that someone at the center of the drug “fighting” business—an industry with its mouth firmly attached to the teet of public funding—actually comes out and admits the truth. So when a drug Czar says so, perhaps some of his counterparts should listen.
Pity that it’s the Scottish rather than American drug czar who’s saying just that. But he at least comes from a place that has a real problem (remember Trainspotting) and an even more Calvinist past than we have over here. So there is perhaps some hope in the madness, although not much I’ll admit.
