For most Americans, $280,000 might represent the price of a home or perhaps their entire retirement savings. But for the 1.3 million people in this country stricken by rheumatoid arthritis (RA)that quarter million dollars could be their drug bill.
Rheumatoid arthritis is a debilitating disease that causes painful inflammation and swelling of the joints. Left untreated, it can lead to permanent disability. Thankfully medications such as Enbrel, Humira and Zeljanzcan keep patients healthy enough to stay active and keep working. Yet the price tag is quickly becoming out of reach.
One recent report from Express Scripts found that spending on drugs that treat inflammatory conditions such as arthritis rose 25 percent in the last year alone. The annual cost of treating the nation’s RA sufferers is expected to reach $9.3 billion by 2020 – a 45 percent jump from 2013.
For a 45-year-old patient recently diagnosed with RA, the lifetime cost of medication is likely to exceed $1.4 million. Even if that person has 80 percent of their costs covered through insurance, the math works out to $280,000 in copays alone.
There’s something out of kilter when families may be forced to choose between investing in a home or easing a loved one’s pain. Yet that is exactly the sort of Catch-22 some will face if we do not find a sensible way to price drugs.
When I started medical school, my South Asian immigrant parents quietly hoped I would find my way to cardiology or another glamorous specialty. Instead, I spent a decade — first as a medical student, then as an intern and resident in internal medicine — focused on advancing the right to health among poor people and others with little access to quality health care.
Through high-impact nonprofit organizations, political campaigns, and grassroots organizing in urban communities and among health professionals, I was part of an incredible community focused on making American medicine better, safer, and affordable to all.
So when it came time for me to find a “real job” after my residency, I assumed it would be in a nonprofit organization with a laser-like focus on transforming underserved health. Imagine my astonishment, then, to discover my life’s work in Iora Health — a private sector, venture-backed, for-profit primary care startup.
Profit and medicine
Critics have said that for-profit medicine makes money by finding ways to avoid caring for sick people “in their time of greatest need.” It’s also been pointed out that the Hippocratic oath doesn’t mention “money, financing, or making a profit.”
The health care mainstream is investing in a variety of mechanisms to beat back America’s health care cost and quality crisis – ACOs, medical homes, data analytics, practice transformation, technology and app integration, patient engagement and decision support – but few have borne fruit. Hidden in our system, though, are companies with unique and successful approaches. For example:
There are companies that, by collaboratively working on different parts of drug spend, consistently reduce pharmacy cost by 30-50 percent. This can result in savings of 6-12 percent of an organizational purchaser’s total health care spend, a huge amount!
Another company uses a physical therapy-based approach to manage musculoskeletal disorders, and can intervene in about 80 percent of cases. Its work with more than 30,000 patients, including in Fortune 100 firms, shows that it gets wildly better health outcomes – pain reduction, improvements in range of motion and activities of daily living – in half the recovery time and with more than a 35 percent reduction in the cost of conventional orthopedic care. Recidivism events that occur over the long term drop by 50 percent. They’re so confident of their approach that they’ll guarantee improved outcomes with a 25 percent reduction in cost.
In 1729, a bold and innovative thinker named The Very Reverend Jonathan Swift made “A Modest Proposal,” the subtitle of which was “For Preventing The Children of Poor People in Ireland From Being a Burden to Their Parents or Country, and For Making Them Beneficial to The Public.” One more thoughtful suggestion by Sir Jonathan was that Irish children, if prepared properly, made fine eating, having been assured by a “very knowing American…acquaintance” that at a year old, they are delicious, “whether stewed, roasted, baked, or boiled.”
While that suggestion never did catch on, it did represent a different insight as to a possible solution to a seemingly intractable problem, and it provoked quite a discussion. We have a new such problem, and it has to do with physicians. Today’s physicians, in their quiet moments, usually admit that their profession and they are in deep trouble. Physicians too often work too hard for too little; they spend too little time on what they consider to be the “practice” of medicine; they believe they are disrespected by hospitals and insurers; primary care docs envy specialists; specialists despise hospitals; and worst, they just flat do not like their day jobs to the point that there is rampant burnout, anger, and depression. Not quite Marcus Welby.
It starts after med school, if not during. The plight of newly “minted” physicians is dire. Unless they come from families of wealth or get some miraculous form of a free ride, they end their education and training with debt often exceeding $200,000. And given the length of time it takes for them to start making decent income, they will have lost at least 8 years of saving and investing, plus the time they need to pay that debt back. They also have to purchase exorbitantly priced malpractice insurance. Meanwhile they do things like get married, have children, and buy houses and cars, like many other professionals. Their plight is well described in a recent article which should cause even the most idealistic young man or woman to think twice before entering medicine. The burnout and depression statistics of practicing physicians today are astounding.
Charles Ornstein is an award-winning healthcare journalist who recently wrote an article in the Boston Globe about an ongoing controversy regarding a top medical publication. Yet Ornstein still wonders about the current status of medical journals:
To help answer Mr. Ornstein’s query, I have asked the editors of top medical journals to submit responses to a simple questionnaire. Here are their answers.
What would an alternative title to your journal be? The Journal of Transparent Research
What is your tag line? “Leading the charge against conflicts of interest”
What happened at your most recent editorial staff meeting? We discussed possible strategic partnerships with healthcare journalists to get Freedom-of-Information-Act orders. Independent observers should be able to get patient-level research data released from the clutches of industry and their puppet scientists and journals.Continue reading…
A reporter who covers healthcare asked me a thought provoking question recently: Is there a mandate for the adoption of telehealth? The inquiry makes sense. After all, from hospitals to health plans, employers to private practices, it is expected that the global telemedicine market will expand at an annual rate of 14.3 percent through 2020. Surely the explanation has something to do with the presence of a national requirement.
And it is the case with other health technology. As many in the industry know, the federal government mandated the adoption of electronic medical records (EMRs).The US Department of Health and Human Services spent billions to implement the Health Information Technology for Economic and Clinical Health (HITECH) Act. And providers were incentivized and penalized based not only on their adoption of electronic health records, but on the efficacy of their “meaningful use” of these new tools.
Of life’s two certainties, death and cataracts, it seems statins defer one and prompt the other, although not necessarily in the same person. If you blindly love life you may be blinded by your love for life.
In the HOPE-3 trial, ethnically diverse people without cardiovascular disease were randomized to 10 mg of rosuvastatin daily and placebo. The treatment group had fewer primary events – death from myocardial infarction (MI), non-fatal myocardial infarctions, and non-fatal stroke. For roughly ten MIs averted there were seven excess cataracts. Peter may be blinded without being saved. Paul may be saved without being blinded. And then there is Rajeev who may be blinded and saved. But the very nature of primary prevention is that you don’t know you’re Peter, Paul or Rajeev. So everyone is grateful to statins. Not even God of the Old Testament had such unconditional deference.
Once you’re taking statins there is no way to disprove that any and every breath you draw is because of statins. Statins enjoy the metaphysical carapace, the immunity from falsification, which not even God enjoys. At least you can experiment with God. Don’t pray for a week and see if you’re still alive- you know if God really cares about prayer-adherence. Even if you die at age 55 on statins, you can never disprove that you wouldn’t have died sooner if you weren’t taking statins.
In 1985 I had the good fortune to study in Sweden. I made many good friends and loved the natural beauty. I also learned a lot about healthcare in what is essentially a socialist country.
Sweden was (and is) by no means perfect. Progressive taxation had disincentivized hard work leading to something of a brain drain. Many of the physicians I met were looking to emigrate. On the flip side, Swedish healthcare was accessible and high quality. The government viewed healthcare as a responsibility and right rather than an option. The relatively small and homogeneous population (8 million in 1985) allowed central planning. On the campus of the Karolinska Institute, their version of the NIH, there were regional specialty hospitals: a hospital for the heart, the G.I. tract, the nervous system, etc.
This contrasts with American healthcare where hospitals offer specialty services on nearly every corner. Here in Phoenix, a patient with cancer can choose from Banner / MD Anderson, Mayo Clinic, Dignity Health / UA Cancer Center, and Cancer Treatment Centers of America, along with several other institutes. How did such choice come about? As a nation, we hold certain truths to be self-evident. Near the top of the list, we believe competition is a good thing. In just about every business open markets lead to higher quality goods and services and ever decreasing prices. Right? So how come on almost every measure Swedish healthcare trumps the American system? Sweden spends half as much per capita
[JL1] but on average its citizens live four years longer.
A Correction to Unicornius Gorus – Theranos and Zenefits
I have a confession to make, my previous piece entitled Unicornius Gorus –Theranos and Zenefits, which identified these two companies as a new species in the Unicornius genus was not correct.
The problems at Theranos, as reported by John Carreyrou at the Wall Street Journal, just keep getting worse. While its now very clear Theranos has a serious problem with their Edison technology and its ability to produce accurate results, what is perhaps even more glaring is their complete disregard for operating a lab within standards.
Along with the measurement errors, the report by the Center for Medicare and Medicaid Services found Theranos:
- allowed unlicensed workers to review patient test results
- did not properly operate equipment as per manufacturer recommendations,
- lacked proper documentation and signatures and
- failed to meet quality control standards.
Last Wednesday marked the sixth anniversary of the passage of the Patient Protection and Affordable Care Act. As of this week, the five Presidential aspirants have each articulated key changes they’d propose, though polls show interest in the law is largely among Democrats who consider healthcare a major issue along with national security and the economy.
GOP candidates Trump, Cruz and Kasich say they will repeal the law; Democratic frontrunner Clinton says she will repair it, and her challenger, Bernie Sanders, promises to replace it with universal coverage. Some speculate that candidate Clinton’s plan will ultimately mirror her Health Security Act of 1993 that parallels the Affordable Care Act in many respects. But the law gets scant attention on the campaign trails other than their intent about its destiny if elected.
I have read the ACA at least 30 times, each time musing over its complexity, intended results, unintended consequences and hanging chads. At the risk of over-simplification, the law purposed to achieve two aims: to increase access to insurance for those unable to qualify or afford coverage, and to bend the cost curve downward from its 30 year climb. It passed both houses of Congress in the midst of our nation’s second deepest downturn since the Great Depression. Unemployment was above 10%, the GDP was flat, and companies were cutting costs and offshoring to adapt.
The “Patient Protection and Affordable Care Act” soon after became known as the “Affordable Care Act”, and then, in the 2010 Congressional Campaign season that followed its passage, “Obamacare”. It was then and now a divisive law: Kaiser tracking polls show the nation has been evenly divided for and against: those opposed see it as “the government takeover of healthcare” that will dismantle an arguably expensive system that works for most, while those supportive see it as a necessary to securing insurance coverage for those lacking.