Tag: Pharma

PHARMA/PHYSICIANS: Attacking the Rx data stream

So perhaps this is getting serious. Doctors Object to Gathering of Drug Data

If the A.M.A effort succeeds, "legislators will turn their attention elsewhere, and the industry can hang on to one of its most valuable data sources," according to an article this week in the industry trade magazine Pharmaceutical Executive, which was co-written by an A.M.A. official and an executive with the leading vendor of prescription data. Even many critics concede that patients’ privacy is apparently not an issue, because the tracking systems identify only the prescribing doctors, not patients. But many doctors find the use of the data by sales representatives an intrusion into the way they practice medicine."These doctors were outraged that people came into their office and talked to them about how many times they prescribed a particular drug," said Dr. John C. Lewin, the chief executive of the state medical association in California, one of the states where complaints about the current system arose.  The California group is beginning its own program under which doctors who do not opt out under the A.M.A. system will get comparisons of their prescribing patterns in 17 classes of drugs from the data companies, said Dr. Lewin, who added that the program was being started as a pilot effort that he hoped would be extended statewide.

This latest dose of outrage is almost hysterical. In both senses of the word.

There are some doctors who are vehement in their opposition to drug companies. They won’t take the free lunch. There are some who take advantage. For most, they have a fairly neutral opinion of drug reps. But the concept of not allowing anyone to know their prescribing patterns doesn’t exactly smack of the transparency that we’ve heard so much about. And frankly if the drug companies don’t know how to detail docs as efficiently as possible (and for that they do need the data) it’s likely that their marketing efforts will get more unfocused and more onerous on the system as a whole. And in general I’m of the belief that useful targeted marketing & sales is better than blanket non-targeted efforts. So unless we are going to ban ALL pharma marketing (which will mean tossing a great deal of useful babies out with the bath-water) and fundamentally change how information about drugs is communicated to physicians, then getting rid of the IMS type data is not helpful.

TECH/PHARMA: Making use of patients while they wait

I have an an article in today’s Health-IT World about technology in the physician waiting room. It features a couple of interesting companies including Phreesia and VisionTree. I met the Phreesia guys in New York recently and played with the product a little. I think as a patient it would be fun and very useful. And it has lots of potential to help out doctors and their office staff. And of course, it’s a great venue for DTC. How the Phreesia guys handle that is to be seen, but frankly useful and not necessarily branded communications about conditions in the physicians’ wating room should be a win-win for everyone.  After all more targeted DTC is better, right?

Full Disclosure-Phreesia is an advertiser on TCHB. VisionTree isn’t. But I like them both! And as you may have guessed I’m not exactly getting rich off THCB advertising.

POLICY/PHARMA: Part D–Lying with numbers

The filthy commies at the Wall Street Journal are out doing themselves this week. Not only attacking Bill McGuire for being a(little bit too) successful capitalist, but now attacking our beloved government on the way it counts Medicare Part D enrollment. And boy is that 30 million number convoluted. Here’s the WSJ article basically in full liberated from behind their firewall. You may note that it’s basically what I, Kate and the rest of the gang over at TPMCafe’s Drug Bill Debacle blog, Joe Paduda and others have been saying for months—voluntary enrollment in this plan is low, and may be too low for it to avoid adverse selection. Read on to figure out how and why

Are Medicare Estimates Too High?Government Says 30 MillionAre Enrolled in the ProgramBy SARAH LUECKApril 21, 2006

At first glance, information released Thursday by Medicare seems to indicate that 30 million people are getting prescription-drug insurance from the federal health program for the elderly and disabled.

Not exactly.

Despite the headline on a government press release — “30 million Medicare beneficiaries now receiving prescription drug coverage” — a smaller number is actually enrolled in the new program, and some of that group had coverage before. As of April 18, 19.7 million beneficiaries are getting drug insurance from Medicare. Of that group, 5.8 million already had coverage from Medicaid, the state-federal program for the poor. An additional 6.8 million people are getting drug coverage from former employers; the coverage is partially subsidized by Medicare. That means a total of 26.5 million people now are benefiting from the Medicare drug program.

To get to 30 million, government officials also counted 3.5 million people who have drug coverage from the military’s TRICARE program or federal-employee benefits, but aren’t signed up for the Medicare benefit. Christina Pearson, a spokeswoman for the Department of Health and Human Services, says the Medicare beneficiaries, regardless of source of coverage, “were able to make the choice that works best for them” because of the new drug-benefit program.

To judge the progress of the enrollment effort, it’s important to account for Medicare beneficiaries who have drug coverage from other sources because they aren’t likely to sign up for the new program. In addition to the 3.5 million Tricare and federal government retirees, an estimated 5.8 million Medicare-eligible people get drug access through the Veterans Administration, their current employers or companies not taking a Medicare subsidy.

When people with other sources of coverage are added to people signed up for Medicare drug plans, about six million people remain, and presumably don’t have drug coverage. This group is the target of the massive campaign by the government, insurance companies and consumer groups to maximize enrollment by May 15.

The Medicare drug benefit has become a political issue, with Democrats criticizing it as too confusing for many seniors. Enrollment numbers, too, have become a flashpoint, with Bush administration officials saying they have “passed their projections,” as Health and Human Services Secretary Michael Leavitt said Thursday. A critic of the drug benefit, Medicare Rights Center President Robert M. Hayes countered, “Every few weeks the administration lowers its standard for success.”

Ms. Pearson, the HHS spokeswoman, said that’s not true. “We’ve consistently said our goal was 28 to 30 million,” she said. “And by any measure we’ve surpassed that goal.”

In fact, Mr. Leavitt and Medicare chief Mark McClellan, have used that estimate since last year, citing Wall Street analysts. A higher projection by Medicare actuaries, of 39 million, was published in the Federal Register in Jan. 2005. That, too, included retiree plans. Now, the actuaries’ projection is lower, at 37 million as of February. Medicare has not yet said why.

Dan Mendelson, president of Avalere Health LLC, a Washington-based consulting firm, and a former Clinton administration official, said the numbers are consistent with what he had expected. “I think they’ll pick up another group of enrollees before the deadline, maybe a million. Then everyone will squabble over whether it’s a big number of a small number.”

At the recent WHCC congress an audience member (well, as I had control of the question device I’d better admit that it was me) asked this question of Abby Block, the person at CMS who runs the program. Here’s the take from my post earlier this week.

There’s more than a little obfuscation about these numbers, especially the 29 million number. How many people over 65 now have drug coverage who did NOT have it before? Abby: that number cannot be determined! We know how many have enrolled but we don’t know what they had before

So rationally we know that only a maximum of 7 million people could have new coverage, and of course some of those had coverage anyway before even if it wasn’t as good. So as the bill is supposed to cost $900 billion over 9 years or whatever tehe final estimate was, we’re spending some undisclosed number north of $100 billion a year, to get drug coverage to less than 7m million people! This to me sounds damn expensive. Then of course cynics can note that not all that money is going to the patients. A few other people are getting their palms greased in the process. Another article in the WSJ today (this one’s free) points that out pretty clearly….and you know who they are!

POLICY/PHARMA: WHCC-Medicare Part D with AARP and CMS

Abby Block from CMS and John Rother from AARP

Abby says 6.4 million in PDPs…29 million have drug coverage overall (although that counts everyone).

What have they learned from Part D? A bunch of stuff about monitoring plans and their operations, appeal management, pharmacy relationships are on their mind (Surprise, surprise). Based on the applications for 2007 the program seems to be healthy. “Going to be sure that they have adequate coverage for 1–800 Medicare and going to be sure that the plans will have adequate coverage too”.

Many things that we’re still working on but the glass is more than half full.

John Rother— it’s a terrific benefit for those who are using large number of drugs/high cost, and for those who are in lower income, But it’s not meeting expectations in the enrollment of low income seniors.  That’s the group for whom  it offers the most value but we’ve only enrolled 20% of them! That’s a tragedy. the program is stable.

To make it better need to something about price/cost control, and also to remove the asset/income means testing in the premiums, as this punishes those who’ve done the right thing.

Medicare is finally taking the leadership of becoming a health care program not just a payment program, so Medicare must keep pushing. The costs that Medicare encurrs are part of the whole system, and we must address the whole system.

How well are the private companies doing in negotiating prices?

Rother—better than CBO projected, but terrible compared to any other country in the world.Block—it’s been very encouraging and the plans have had significant impact

There’s more than a little obfuscation about these numbers, especially the 29 million number. How many people over 65 now have drug coverage who did NOT have it before? Abby: that number cannot be determined! We know how many have enrolled but we don’t know what they had beforeRother: said that 1/3 last year had no benefit and 1/3 had inadequate benefit….the test of the program will be seeing that difference when the data is in. Abby: Have a huge outreach effort trying to get low income people to enroll. But that has been a huge concern.

What about delaying the penalty date?

Abby: A firm deadline makes sense., If you delay it. people will delay. This month we’re seeing a big increase, because of the deadline.John: The deadline is to encourage healthy people to enroll. Not appropriate for the low income population and that will be extended. But this may be revisited as a 7% increase on premiums may cause a political problem!

Do you feel the AARP run Part D product places the organization in a conflict of interest trough being a third party senior advocate as well a provider of the good?

John: No! We think that’s a good value plan for our members and its an arms length relationship internally.

Will there be more legislative fine-tuning?

Abby: we hope not!John: we hope so, on delaying enrollment, on formulary lock-in and demanding secretarial authority on, and perhaps requiring plan sponsors to only offer two plans.  We want fewer better choices than the mass confusion we saw earlier this year.Abby: We want stable formularies, but there is good reason to allow change when new generics come in, and some other reasons (such as drug price changes)

Will CMS provide aggregate data on what percent of mfr rebates were passed on to patients in the coverage gap?

Abby: 100% of rebates are passed on in the coverage gap (of course she doesn’t mention that rebates are just one way of hiding the money between pharma and PBM without passing it on to end customers…)

What tradeoffs do you see (and would you accept) between limiting innovation in pharmaceuticals and lowering unit costs for today? Does it make better sense to try to measure total value from enhanced Rx payments versus improvements in beneficiaries’ health status/reductions in Part A & B spending?

John: Price and innovation aren’t connected, especially with twice as much being spent on pharmaceutical  marketing as on R&D

Given the number of plans and continued questions from seniors, do you anticipate longer open enrollment periods in the coming years?

Abby: Need a longer open enrollment period and launch a campaign to get people to enroll earlier. Number of choices will be reduced as the consumer shows what they’re interested in buying. We want clearly differentiated products that beneficiaries understand.

Why has the enrollment for low income seniors been so low, as the bill was basically set up for them and benefits them the most?

Abby: Well there’s an application form, and its complicated for them. But here is a point of sale application form and people who weren’t enrolled thought they were and got it at the pharmacy

John: Only face to face enrollment works. Language and health literacy issues, and many people don’t want to fill out their information, especially about the asset test. AARP is funding a campaign through churches, and there are lots of meetings set up. But it’s slow going.

How will this be different in 5 years?

Abby: It’ll be taken for granted….John: Depends on who’s running the government; Democrats would probably get rid of asset test, have a separate benefit. The other issue is the price behavior of Rx. If they head up fast, there’ll be congressional intervention.

TECH/QUALITY/PHARMA: Active Health used by Mariott

Interesting brief presentation — Mariott uses Active Health Mangement to change its formulary

Integrates pharmacy, medical and labs data from one place—inluding diagnosis and runs it against the medical literature based algoritms. They then communicate information to both providers and consumers (in consumer friendly langauge).

They found that sometimes “care considerations” has been presented to doctors and they’ve reported back that the script was written but the patient counldn’t afford it. So some medications (what they called essential rather than non-essential drugs)they’ve selectively changed the formulary to a lower copay, or none for generics, for those that have the relevant disease. Care engine can both identify those on the drugs and those who are not but should be, and communicates that information back to doctors and patients.

They’re doing a pre & post compare study with another Active Health Client who is not varying copays to see what that does to adherence and cost outcomes. The program is great reminder for docs and patients. Trying to ensure that the essential drugs are acessible.


PHARMA/POLICY: Libby on the war on Pain Doctors

Ron Libby, a political scientist at University of North Florida, is one of the few academics looking at the war on drugs. He has amassed an array of evidence showing that the incredible and pernicious behavior of the DEA has led to an epidemic of untreated pain. His piece is available here—Treating Doctors as Drug Dealers: The Drug Enforcement Administration’s War on Prescription Painkillers.

Meanwhile lunatic politicians continue to spout crap on the subject. The real number of people in Florida dying from Oxycontin overdoses may, just may, have been as high as 71.  Not the 500 that a series of totally discredited articles in the Orlando Sentinel published. But just yesterday this rubbish ran in the Fort Myers News Press.

Sgt. Lisa McElheney, who heads Broward County’s
drug diversion unit, said even when law enforcement are tipped off
about a doctor over-prescribing drugs like Oxycontin, they often don’t
have the manpower to follow all their leads. “Most of these drugs are going through legal channels,” she said. Six
people a day die in Florida from prescription drug abuse, according to
the Florida Office of Drug Control. House and Senate versions of the
bill are still in committees.

Tell me that the average reader looking at that wouldn’t think that 6 people a day or 2,000 a year are dying from Oxycontin in Florida. 2,000 a year may be dying from prescription drugs in Florida, but not from Oxycontin–more likely from drug-drug interactions and medical errors related to them (assuming that the IOM’s 100,000 patient deaths number is correct).

This is more shameful hysteria with real and bitter consequences.


POLICY/PHARMA/POLITICS: Losing it with the WaPo

It’s interesting tracking intellectual BS. The latest one is all the surveys selecting only people who have signed up with Part D and then reporting their experience, without mentioning that they’re likely to be happy because it’s a self selected group! And of course not surveying those who didn’t sign up about their experience. Over at TPMCafe I explain why the Washington Post continues to look like a bunch of idiots for using the Administration’s data, and—worse—for commissioning a survey continuing the lie!

POLICY/PHARMA: Yup some do benefit from Part D. This is not news! And politically it won’t matter. with UPDATE

After all the yarling and snapping of the introduction of Part D, there was a curious article in the New York Times on Sunday suggesting that "For Some Who Solve Puzzle, Medicare Drug Plan Pays Off." Of course this is not exactly news. Several of us said at the time that the plan would improve the financial well being of lower-income people not poor enough to Medicare who were heavy Rx users and would now have catastrophic coverage. A real study funded by Kaiser FF said exactly that in 2004. In fact it’s headline was


And that report’s summary said:

Low-income people with Medicare
who sign up for new Part D drug plans and receive the additional subsidies – an
estimated 8.7 million people – are projected to pay 83 percent less for
prescription drugs in 2006 than they would have spent if the Medicare drug law
had not been enacted, according to a new report released today by the Kaiser
Family Foundation. Those who enroll in the new drug benefit but do not receive
the low-income subsidies – an estimated 20.3 million people — are projected to
pay on average 28 percent less out of pocket for their prescription drugs as a
result of the new law, the analysis finds.

Of course that all was based on a higher forecast of enrollment than it looks like we’re currently seeing.  But that means that if you enrolled and you fit into that category, then you will be paying less. In fact an independent pharmacist quoted in the NY Times article gets it basically right.

Todd E. Pendergraft, owner of a Medicine Shoppe pharmacy in Broken
Arrow, Okla., outside Tulsa, said the new drug coverage was
"significantly beneficial" to one-third of his 750 Medicare patients,
"marginally beneficial" to half the patients and "no benefit at all" to
the remainder.

Because it’s of no benefit to most, and will eventually mean a reduction in employer retiree benefits, on a purely political basis I advocated Kerry running heavily against the bill in 2004. While he never really mentioned it (and my meager attempts at the time to get Democrats to pick up on it were ignored), it’s still a hot issue in 2006, and one that now will be picked up on politically. Of course because of the incompetence shown during the transition to the new program, it’ll be run on in the Katrina/Iraq incompetence meme, rather than the "destruction of Medicare" meme.

But the flat answer is that, yet again, because not everyone is put in the same pool (i.e. seniors are not forced to buy into Part D) there will be adverse selection amongst those who do. That adverse selection is coming from the people who are now better off (because they wouldn’t have bought it if they didn’t think they would be). Eventually in a couple of years the PDPs will start losing money, jacking up their rates and upsetting their senior customers — and the  subsidies hidden in the bill for those PDPs start reducing at around the same time. Just as happened with Medicare HMOs in the late-1990s.

If you really wanted to run a proper drug benefit using private plans, you ought to force everyone to join so that you have a universal risk pool. But of course Congress would never dare have done that politically after the experience of Medicare Catastrophic in 1988 nor would they have forced the employers to pay into the pool for their retirees. So we get the hodge-pot we’ve got, with all the confusion and angst it’s caused amongst seniors.

And of course we’ve got two calendar issues coming up. The first formulary switch and the first donut hole "approachees".

Beneficiaries could face new problems in coming months. Insurers can
impose stricter limits on access to certain drugs after March 31, when
a 90-day transition period ends. In addition, some beneficiaries will
have to pay more at the pharmacy counter, because most drug plans have
a gap in coverage after a person’s total drug costs reach $2,250. The
gap lasts until the beneficiary incurs total drug costs of $5,100.
Beyond that point, Medicare pays about 95 percent of the cost of each

The argument in favor of the formularies is that this is how private sector drug plans work. But CMS isn’t going to make much headway with the line that "formulary restrictions are how the private sector PBMs work" because seniors are rather more interested in their health care than working-age Americans. Somewhere at the end of this calendar is an election, I recall. And I can see the Ad now "Part D is worse than Medicare and those Republican bastards forced me into it."

And did you know that the very law creating Part D bans Medicare from negotiating with those evil bloodsucking pharma companies, even though the VA is allowed to? I suspect you did, and if you don’t you will by November!

CODA: You might want to see my other post this morning for a link to much more discussion about Part D.

UPDATE: And then there’s the power of the headline. Of course the entirely disinterested AHIP Solutions SmartBrief newsletter puts a slightly different spin on the story:

More praise from Medicare drug program
Despite reports of some problems with the Medicare prescription drug
program, some customers say the benefit was worth the sometimes confusing and
complex process of enrolling. People in places such as Tulsa, Okla., who were
more removed from the political debate about the program, say friends and family
helped them with the choices and the outcome is satisfying.

PHARMA/POLICY: Medicare Part D, yet more to and fro, and some on the uninsured too

A long transcript from a conference full of health care journalists (hat-tip Kasier FF) in which Leslie Norwalk from CMS proves that she’s very brave, or maybe even foolhardy.  And apparently Medicare Part D was all Al Gore’s idea….. Bob Hayes from the Medicare Rights center, Susan Jaffe, from the Cleveland Palin Dealer and Stuart Gutterman from Commonwealth, don’t exactly agree.

Well worth a quick flip through.

There’s also one on the uninsured which is horribly transcribed, but suggests that some of the reporting about Dirigo care in Maine has been wrong, including one that I picked up on in my Spot-on piece on why we need ONE insurance pool.

Here’s what Joe Ditre, executive director, Consumers for Affordable Health Care, says about the WSJ opinion piece and it does indeed sounds as though the insurer-backed Council for Affordable Healthcare which wrote the articel with a local right wing think-tank has been caught with its hand in the statistical cookie jar:

the Main Heritage Policy Center and they put out this piece that basically said that in the state of Maine that the Dario Program had …only twenty two-percent of all enrollees were previously uninsured. The fallacy is that they based that statistic on one quarter of enrollment which did not include the individuals who enrolled. Again, Dario covers small businesses and individuals, so they focused on the very first quarter of the program’s operation in which no individuals were allowed to enroll because they had to enroll in the second quarter. So they took that percentage, twenty two-percent and what did they do they applied it across the entire enrollment for the first year only sixteen hundred people were uninsured. Now, that’s problematic from any point of view but it is the story that has stuck in the state but one the government didn’t respond quickly enough to basically take away or say that’s false but too, these mouthpieces have been able to get this story, it was in the wall street journal, if you saw that story, and it was printed up on the Kaiser website, I mean on their you know their coverage of the when they do that sweep of the national stories it gets repeated everywhere and it’s false.The real number of uninsured is forty four-percent of them are uninsured overall, within the individuals it’s fifty-percent,– of the ten thousand forty four-percent overall are uninsured, were previously uninsured


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