Category: Uncategorized

The Top 10 Generics

Jun 29, 2010• 1

By ED PULLEN, MD

Many of the breakthrough drugs of the 1980-1990′s are now available
as generics, and pharmacy competition has led to great bargains for
patients needing these drugs.

The 1980’s and 1990’s were a golden age in the development of great
new drugs to treat many common and uncommon diseases. Prior to that
time it was very difficult to treat depression, hypertension,
diabetes, and congestive
heart failure. It was nearly impossible to treat high cholesterol.
Breakthrough drugs like the SSRI
antidepressants, ACE
inhibitors and calcium
channel blockers for hypertension, metformin
for diabetes, and several drugs in combination for congestive heart
failure came to market, and have revolutionized the care of many of
these chronic diseases. Now the great news it that many of these drugs
are available as generics, and competition between retail pharmacies has
led to incredibly cheap medication. Here is my top ten list of great
generic medications.

ACE inhibitors. I tend to use lisinopril, but
several others are also available. These meds are effective at
controlling high blood pressure, but have also been shown to prevent
heart attacks in patients post MI, to prolong life and reduce
hospitalizations in congestive heart failure, to prevent diabetes
related kidney failure, and is usually extremely well tolerated. A
small percent of patients get a cough, and even smaller percent are
allergic to these medications.
Statins This class of LDL cholesterol lowering drugs has made effective treatment of high cholesterol practical and simple. Several have gone generic including simvastatin, lovastatin, and pravastatin. Although simvastatin (Zocor) is not on the chain pharmacy $4. drug lists, it is quite inexpensive ($10.90/ 100 40mg doses at Costco) and is effective enough for most patients to achieve goal LDL cholesterol levels. Many studies have shown statins to be effective at lowering rates of various cardiovascular diseases.

Heavy Words

Jun 28, 2010• 21

By ROB LAMBERTS, MD

The post that forever doomed the world to have my writing forced onto them was one called Shame, in which I describe my frustration with how society stigmatizes people who are obese. It was picked up by the NY TImes Health Blog and got a good conversation about the subject going on the blog-o-sphere.

A recent article in EverythingHealth (via Better Health) got me thinking again about the subject of society’s response to the “obesity epidemic.” The article discusses a recent study that showed…well, read it for yourself:

Talk about a cruel trick of nature! A study funded by the National Institutes of Health (NIH) and published in JAMA shows that physical activity prevents weight gain in middle-aged and older women ONLY IF THEY ARE ALREADY AT IDEAL WEIGHT. Did you read that? It means that the recommended guidelines advocating 150 minutes of exercise a week isn’t sufficient to prevent weight gain in most middle age women.

The author, Dr. Toni Brayer, ends the post by saying:

So what are we to think about this study? First, caloric restriction is the only way to maintain or lose weight. The health benefits of exercise have been proven over and over in thousands of studies and that is not in dispute. But weight control demands caloric restriction, period.

I am sorry about these results. Truly I am.

Hearing the frustration from my patients (male and female), and struggling with weight myself, I have to say that this is not really that surprising. Losing weight is not easy. Let me say that again: losing weight is not easy. There are lots of reasons it is difficult to lose weight, from the food-oriented culture to a person’s own metabolism. There are emotional and addictive aspects to obesity as well. This study puts scientific evidence behind the hardness of weight loss.Continue reading…

Contradictions in Massachusetts

Jun 28, 2010

By PAUL LEVY

I have written before
about the strange things going on in the Massachusetts health care
insurance market. For those from out of state, here are some quotes
that will give you a sense of the contradictions in the public policy
arena.

They are, respectively, from two stories that appeared on
the same day in the Boston Globe:
"Rate
cap for insurer overturned" and "Officials
give up cutting health perks."

(1) An insurance appeals board yesterday overturned the state’s
cap on health premium increases for small business and individual
customers covered by Harvard Pilgrim Health Care . . . [finding] that
rate increases Harvard Pilgrim initially sought in April are
reasonable given what it must pay to hospitals and doctors. That ruling
trumped the Insurance Division’s earlier finding that the requested
increases were excessive.

(2)
The state’s public employee unions won a major victory this week when
the Legislature abandoned efforts to allow cities and towns to trim
generous health care benefits enjoyed by thousands of municipal
employees, retirees, and elected officials.

You can read
the rest and related stories, but what is most disturbing is that the
spirit of cooperation and compromise that existed when Massachusetts
approved its health
care reform law in 2006 has broken down. Part of the reason is
that commitments made at that time have not been delivered upon. For
example, the state had promised to lift Medicaid payment rates to
something closer to the cost of delivering that service. Once the
economy sank and state budgets were stressed, that was not possible.
This left providers needing to collect more of their income from private
insurers.

If HIT Plan A Doesn’t Work, What’s Plan B?

Jun 28, 2010• 42

By VINCE KURAITIS, JD, & DAVID KIBBE, MD

Pop quiz: Among early-stage companies that are successful, what percentage are successful with the initial business model with which they started (Plan A) vs. a secondary business model (Plan B)?

Harvard Business School Professor Clay Christensen studied this issue. He found that among successful companies, only 7% succeeded with their initial business model, while 93% evolved into a different business model.

So let’s take this finding and reexamine our human nature. In light of these statistics, what makes more sense:

Defending Plan A to your dying breath?
Assuming Plan A is probably flawed, and anticipating the need for Plan B without getting defensive?

We question many of the assumptions underlying HITECH Plan A. We also want to talk about the need and content for Plan B in a constructive way.Continue reading…

Are Doctors Really Boycotting Medicare?

Jun 28, 2010• 25

By NAOMI FREUNDLICH

As Congress once again wrestles with “the doctor fix”—yet another postponement of the 21% cut in Medicare reimbursement that went into effect this month—the media has been swirling with stories warning of a mass exodus of doctors out of the federal program. The reason: In 2008 Medicare paid doctors 78% of what they get from private insurers; with the 21% cut they fear that their income will drop even lower.

The reports hit their peak late last week—USA Today wrote that “[t]he number of doctors refusing new Medicare patients because of low government payment rates is setting a new high,” while the American Medical Association announced that 31% of primary care doctors are restricting the number of Medicare patients they take. In a recent survey, the American Academy of Family Physicians found that 13% of respondents didn’t participate in Medicare last year, up from 8% in 2008 and 6% in 2004. Chic Older, executive director of the Arizona Medical Association told the Seattle Times ; “If the 21 percent cut goes into effect, we’re going to have a very severe problem in the state of Arizona.”

The question is: Will Medicare beneficiaries really face a shortage of providers and restrictions on their access to care? Or is this a scare tactic being used for political reasons?

First off, all this is happening against the backdrop of a major political fight in Congress over how much the government should invest in economic recovery. On Friday, the Senate passed a “doc fix” that would postpone the 21% cut in Medicare payments for another six months and provides a 2% increase in reimbursement instead. Unfortunately for doctors—and the seniors they count as patients—Nancy Pelosi has signaled that she may not be willing to settle for such a short-term solution. According to Politico, Pelosi was “caught off guard last week when Reid suddenly opted to pull the Medicare issue out of a jobs and economic relief bill on which the two leaders have been working for months.” For more background on the long history of the “sustainable growth rate” formula that mandates the Medicare cuts (enacted in 1997 by a Republican administration) and the unlikelihood of it ever being instituted long-term, see Maggie’s recent post here.Continue reading…

A Tale of Two Diseases: Repairing Comparative Effectiveness Research

Jun 28, 2010• 4

By DAVID E. WILLIAMS

Writing in the New England Journal of Medicine (Identifying and Eliminating the Roadblocks to Comparative-Effectiveness Research) three authors share their experience in running a head-to-head trial of Avastin (bevacizumab) versus Lucentis (ranibizumab) for wet age-related macular degeneration (AMD). They describe the barriers they faced and suggest that they will need to be removed for comparative effectiveness research –as envisioned under ARRA– to succeed. They make good points and may well be correct in their policy recommendations.

However the case of Avastin and Lucentis is unusual. The products are made by the same manufacturer and are essentially identical. Avastin and Lucentis are marketed separately by Genentech mainly to allow the company to capture a return on investment from its R&D. The issue is that a regular dose of Avastin (e.g., for lung cancer) can be divided up into many doses for the eye. Since the products are sold by volume it turns out that Avastin is cheap when used for wet AMD, even though it’s pricey when used for cancer. As I’ve suggested previously, Genentech should be able to charge Lucentis prices for Avastin when it’s used in the eye. So there are quite a lot of people –starting with the manufacturer itself– who didn’t really want this study to go forward. That’s less likely to be the case with other studies.Continue reading…

RFID Tags for Nurses. Then Everybody?

Jun 27, 2010• 2

By FRANK J. PASQUALE

The recent City of Ontario v. Quon decision has had a mixed reception among privacy advocates. Though many are disappointed that employees’ privacy rights have once again been narrowed, some have discerned helpful dicta in the case. However, I worry that, whatever the drift of thought among swing justices, economic imperatives and cultural shifts will mean a lot less privacy in the workplace of the future. Health care in particular offers a few interesting bellwethers.

As an opinion piece by Theresa Brown explains, maintaining proper staffing levels in hospitals is becoming increasingly difficult. Surveillance systems are offering one way to address the problem; work can be performed more intensively and efficiently as it is recorded and studied. But such monitoring has many troubling implications, according to Torin Monahan (in his excellent book, Surveillance in a Time of Insecurity):

The tracking of people [via Radio Frequency Identification Tags] represents a . . . mechanism of surveillance and social control in hospital settings. This includes the tagging of patients and hospital staff. . . . When administrators demand the tagging of nurses themselves, the level of surveillance can become oppressive. . . . [because nurses face] labor intensification, job insecurity, undesired scrutiny, and privacy loss. . . . To date, such efforts at top-down micromanagement of staff by means of RFID have met with resistance. . . . One desired feature for nurses and others is an ‘off’ switch on each RFID badge so that they can take breaks without subjecting themselves to remote tracking. (122)

Like the “nannycam” employed by many a wary parent, the nurse-cam may be seen as a way to protect the vulnerable. It may also increase the accuracy of evidence in malpractice cases. On the other hand, inserting a tireless electronic eye to monitor what is already an extremely stressful job may create many unintended consequences, or deter people from going into nursing altogether. Even advocates of pervasive surveillance recognize these difficulties.Continue reading…

Do Physicians Have a Right to Privacy?

Jun 25, 2010• 20

By MARGALIT GUR-ARIE

As we move to Electronic Health Records (EHR), the debates over security and privacy are becoming more frequent and more poignant. We of course have HIPAA laws on the books and ONC has a Tiger team assembled to recommend privacy and security policies to Secretary Sebelius. CIOs and entire IT departments are all focused on protecting the privacy of patients and their Personal Health Information (PHI). This is, of course, as it should be, but how about privacy of those taking care of patients? Do physicians have a right to privacy too?

As EHRs become more prevalent and interconnected, increasing amounts of clinical and administrative data will be flowing out of doctors’ offices and into the great beyond. Most of this data is indeed patient data, but some of it could be combined, sliced and diced to derive pretty extensive information about doctors. For example, and in no particular order:

Prescribing patterns – Prescription data has been collected and sold to pharmaceutical companies for decades. EHRs will make this much easier to accomplish and the data will become richer and more granular, since it will contain the exact nature of the visit where a particular drug was prescribed or discontinued, including physician notes on the subject. Of course, such information finding its way to public websites would present a novel difficulty if, say, we can look up Dr. X and see that she wrote 30 prescriptions for contraceptives last month, half of which were for girls under 16 years of age.Continue reading…

The Promise of Medicine

Jun 25, 2010• 14

By EDWARD D. MILLER, MD

Dr. Miller is the Dean and CEO of The Johns Hopkins University Medical School. These remarks were made at the National Press Club, June 21, 2010.

I. The Promise of Medicine

Let me start with a short story: It was the summer of 1971. I had just finished my training in anesthesia at the Peter Bent Brigham Hospital and was about to embark on a two-year fellowship in physiology at Harvard. I was asked if I wanted to be “the” anesthesiologist for the month of August on Martha’s Vineyard. It was to be part vacation and part work, and I needed the money.

Shortly after arriving, a young woman (who now runs a well-known tavern in that community), needed a surgical procedure. She had no insurance but was able to pay the medical bills out of pocket. She, however, could not afford the normal three-day stay in the hospital. She pleaded with me to have the minimal amount of medicine so she could be discharged the same day. To this day, I vividly recall helping her out to her car so that she could recover at home. You see, at the time, there was really no such thing as outpatient surgery.

Thanks to a revolution in anesthetics, outpatient surgery is a very common norm today. In fact, at Johns Hopkins Medicine facilities, we performed twenty-four hundred such procedures just last month.Continue reading…

Private Equity in Health Care

Jun 24, 2010

By FRANK PASQUALE

As lawmakers squabble
over the “carried interest” tax rate, it’s nice to find a big picture
overview of some of the economic activity they’re discussing. I recently
read Josh Kosman’s book The
Buyout of America: How Private Equity Will Cause the Next Great Credit
Crisis, and I highly recommend it to our readers. Kosman painstakingly
describes the byzantine financial maneuvers behind marquee private
equity firms which bought “more than three thousand American companies
from 2000-2008.” He describes in detail how they resist transparency
(164) and “hurt their businesses competitively, limit their growth, cut
jobs without reinvesting the savings, and generate mediocre returns”
(195). The recipe for high earnings is simple: the firms “get large
fees up front and are largely divorced from their results if their
transactions fail” (195).

Like Kwak and Johnson’s account in 13 Bankers, Kosman offers
a political economy account of private equity’s favored treatment by
government. As he notes,

[F]our of the past eight Treasury Secretaries joined the
PE industry . . . . and they have significant influence in Washington.
President Bill Clinton, and both President Bushes, have also advised PE
firms or worked for their companies. . . . KKR retained former
Democratic House majority leader Richard Gephardt as a lobbyist and
hired former RNC chairman Kenneth
Mehlman as head of global public affairs. (196)

Having analyzed a wide array of buyouts, Kosman concludes that “PE
firms manage their businesses to satisfy short-term greed, not for
long-term survival” (51). This is a particularly dangerous attitude in
health care, an industry too long dominated by short-run thinking.