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BLOGS/QUALITY: More ego surfing–me on DM in Pharma Executive

Just in case you missed it, Pharmaceutical Executive interviewed me about a whole range of stuff. Out of that they chose some allegedly wise words I had about Disease Management and EMRs in a feature in the February issue. Interestingly enough they were a little dubious about my statements (that didn’t make it into print) about the coming reduction in the salesforce workforce, and that was a couple of weeks before Pfizer said it was canning 30% of its salesforce.

 

POLICY: The NY TImes tries to make Cutler a star

There’s a long and not too revealing article about Harvard health economist David Cutler in the NY Times magazine. It’s called the  The Quality Cure? and I will try to get to some comments on what’s wrong with it later today.  Meanwhile here’s what I said about it in my FierceHealthcare newsletter

Unlike most critics, Cutler doesn’t think high healthcare costs are necessarily a problem. After working on the failed Clinton effort, Cutler teamed up with another young economist named Mark McClellan to study the economic costs of heart disease. Their contrarian conclusion: Americans are getting their money’s worth when it comes to their healthcare costs, at least in cardiac care. The Times fails to note, however, that many of Cutler’s concepts are either not that new or are contradicted by several other leading health economists.

BLOGS: Grand Rounds up

Grand Rounds is up over at Orac’s blog and it’s done in the style of a TV narrative called What to watch this week. My post is part of Boston Legal, which apparently has James Spader and Captain Kirk in it these days.  I should watch more TV!

PHARMA: The Industry Veteran on the new career choice for ambitious young pharma execs

Forbes has an article out called The Dark Side of Whistleblowing which discusses the growth of somewhat dubious methods to make cash by insiders at the scene of the crime reporting and documenting government rip-offs by contractors, rather than the individual trying to stop the practices themselves. They focus on the case of TAP pharmaceuticals which after its "alleged" misbehavior agreed to pay a fine in order to stay in the Medicare program, but more recently had all its executives involved in the scam if not exonerated, at least found not guilty in their criminal trials. In fact this controversy over how culpable is the whistleblower is famous enough that it’s the basis for a book by John Grisham (on of his better ones, The Partner) in which a whistleblower has in fact secretly set up the scam that he’s blowing the whistle on. (I haven’t given away the main part of the plot so you’re still safe to read it) . In general I don’t think anyone really doubts that TAP was sailing pretty close to and in fact beyond the wind. The entire Medicare Part B, infusion center resale of pharmaceuticals has been rife with little scams for many years, whether they are strictly within the letter of the law or not, and in some ways the recent change in pricing in that market contained in the MMA has got something to do with trying to reduce the level of confusion that makes those scams so possible. But of course the Industry Veteran has a much finer interpretation of the real implications of this issue to those searching out their future in the world of big pharma:

In the piece on whistleblowing from Forbes, The author makes the required genuflections at capitalism’s altar by disparaging the archaic Civil War era legislation and a legal system that pays someone $126 million for ratting out his company.  Despite such obeisance, the sheer facts of the case, together with some reflexive fairness that the author couldn’t quite squelch, obliged him to grudgingly admit that the informer did the right thing even if his compensation does seem excessive. My wry reflection concerns the fact that a young person starting out in the pharmaceutical industry can do good and well by pursuing a career as a whistleblower rather than some other position. I base this on the fact that too many land mines and matters of chance stand in the way of ascending to the CEO’s office where one can earn unconscionable sums in the manner of Hank McKinnell or Sidney Taurel.  On the other hand, the Pharma companies routinely defraud the public and all levels of government, as well as other, large corporations. Given the fact that the various tattlers in the cases cited below came from mid-management positions, whistleblowing certainly appears as a more feasible career goal. 

If I were a schoolkid today and an aunt or a teacher asked me what I wanted to be when I grow up, it’s clear that I’d answer with "whistleblower" because the prospects for risky, exciting and noble activity is greater there than in becoming a fiduciary officer.  It used to be that when kids told their elders they wanted to become firemen, ballplayers or astronauts, their parents would begin deflecting them from these choices in favor of one of the professions or business. These traditional aspirations of the middle class offered the promise of stability, prestige and good money.  The beauty of the whistleblower choice is that it provides kids with the perfect response to parental objections.  "How many people, mom, in business or the professions walk off with a $126 million haul at the age of 53?"

Within the pharmaceutical industry I feel that my words of encouragement represent sermons for the choir.  Even today I see in Reuters that the Justice Department is investigating GlaxoSmithKline for failing to provide government agencies with best-pricing on some drugs.  More creatively still, an Associated Press story announced the premier of a tell-all movie by an ex-Pfizer rep while another ex-Pfizerite has published a tell-all book with its own gory details  about being a Viagra salesman.  In short, if the prospect of cashing in as a whistleblower appears too farfetched, then books and the movies offer a more conservative opportunity to make out by denouncing Big Pharma.

As a quick coda, I was modestly amused that while it may not be the Veteran’s newly preferred way to wealth, the titans of big pharma are still managing to get by.  You may have thought that Merck had a tough year last year, what with the Vioxx problem and that nasty little stock collapse, but that didn’t stop CEO Gilmartin raking in a tidy $34 million in stock options.  Meanwhile the relatively impoverished Hank McKinnel over at Pfizer, where shareholders saw their worth drop 30% in 2004, found that his annual compensation went up 72%, albeit to a mere $16 million — although that doesn’t count even more stock option grants and the use of the corporate jet for personal travel. Eli Lilly’s President Sidney Taurel had according to the Indianapolis Star‘s initial version of events to struggle by on $4.7 million but somehow I suspect that he got an easy ride from the hometown paper which somehow missed the minor fact picked up by the AP and printed in the next day’s paper that his actual compensation counting options was $15 million.  Although the poor chap will have to start paying for his corporate jet rides from now on.

And I know that you Silicon Valley folk think options don’t count, and yes my 200,000 options for my failed start-up were never worth much and now are worth nothing. But being given millions of dollars worth of options "in the money" does count as real compensation, even if there’s a chance that the value of the shares underlying those options can go down — something that shareholders of Merck, Lilly and Pfizer know only too well — as this chart below tells you.

Mlp_stock

POLICY/POLITICS: A despair at the lack of new ideas

A long time THCB friend and contributor is back from the big NMHCC show.  He was not impressed at what he heard:

Just got back from NMHCC in DC last night. I was
shocked – shocked! – at the paucity of any kind of original thought at the
conference.  There were a couple of interesting collaborations between payers
and providers (e.g. BCBS of Delaware providing access to its MeDecision database
to allow them to print patient history reports in Christiana Health System’s
ER), but nothing especially compelling or breakthrough to discuss.  No
substanative discussions (beyond CDHP) about the 45 million uninsured (at least
that I heard) or the millions more that will be with the looming Medicaid
cuts.

HHS Sec’y Leavitt outlined 12 strategies for Medicaid
(I wandered off during number 8, I think: his diatribe about how big a problem
lawyers cause helping seniors who are above the poverty level give their assets to
their kids so that they can qualify for Medicaid coverage of LTC).  His
mandate is clearly to eviscerate Medicaid as we know it… I’m all for progress
(i.e. a better Medicaid that covers more people at fewer cost with less waste,
fraud and abuse and chronic disease) but not for removing a vital safety net for
the indigent and working poor (especially children)…

POLICY/POLITICS: Faith-based health care as the solution for the health insurance crisis

New contributor Susan Mucha has some interesting and amusing takes on the views of the  Republican voting core on the health insurance question:

Excellent thoughts on this topic. I share your frustration on shopping for health insurance–my "association plan" is $6500 a year with a $5000 deductible and it goes up about $1000 a year (I’ve never made a claim). Unfortunately as a member of the middle class, if I had a need for emergency medical care and didn’t insure myself, the hospital would take my
house and savings after presenting the bill, so I choose to pay for a noncompetitive "group" insurance policy rather than play roulette with my retirement. Individual insurance wanted to indefinitely exclude my gastro-intestinal tract (family history of hiatal hernia plus had a screening colonscopy/endoscopy about four years ago–no further treatment but a black mark on my health screening questionnaire).

 
I have some humor to share with you. A member of
our local Republican Women’s group called me last night to see why I wasn’t
re-joining–I’ve refused the last two years because of my frustration on
Administration policies related to health care (the Democrats don’t have better
answers because the insurance lobby feeds both sides too well). I told her that
I felt that the Administration was out of touch on this issue and until I saw
some evidence of it being given attention I wasn’t going to re-join. She shared
with me that she was currently uninsured because her husband was self-employed
and couldn’t find affordable health insurance. She says she "prays to God
every day that she won’t get sick." So, I guess Republican women are starting a
new "faith-based" initiative to address the health insurance issue. Personally I
think the HSA isn’t much better than praying to God to stay well. I’m not
worried about a $5K hospital bill. I’m worried about $100K hospital bill and
because no one knows how much procedures cost, it is impossible to understand
what you are buying in a hospital emergency situation.We definitely need to fix the problem and the report you’ve posted has excellent suggestions. There are a lot of us out here that are willing to pay
for reasonable health coverage insurance and a little better regulation of
insurance industry policies would go a long way in incentivizing continued
individual health cost responsibility. I see more and more people "praying to
God" instead of paying insurance premiums and ultimately we taxpayers are
covering those bets.

I actually think that this is a screaming big deal, and that the social conservatives without access to health insurance are the "swing voters" who will eventually vote for rather than against their economic interests, and vote for a national health insurance program.  How long they’ll stay with faith-based insurance, I don’t know.

BLOGGING: Minor IE screwup

There was a minor screw-up in the template today and that meant that Internet Explorer and Safari users couldn’t get to the site for a while.  My apologies.  It’s now been fixed, but for your techies out there you’ll be interested to know that Firefox worked just fine.  If you try to get to the site and it doesn’e work, please email me about it.  Thanks

QUALITY/TECH: ePrescribing as part of P4P for Wellpoint

In more from the HIT conference, Leo Barbaro the network management services VP for Wellpoint Northeast (Blue Cross NH, Connecticut, Maine) gave a talk in which he jammed together an ePrescribing talk with his P4P talk and gave some ideas about what’s working to combine P4P and encourage ePrescribing as part of it. It’s an excellent talk with lots of info, and you can download a PowerPoint of it here.

Wellpoint is moving towards P4P for all products, rather than just for HMOs. They’re also starting to move quality payments away from HEDIS measures to paying for IT use.  Now that Wellpoint is big enough to swing a bigger stick in many markets they’re starting to consolidate their P4P programs.  In the 3 states Barbaro runs they give physicians points for doing the right thing. You can get 15 points out of 100 for adoption ePrescribing and another 25 if you prescribe all the generics you could.  And if a physician gets to 80 points out of a hundred they get a 6% bonus payment on top of the FFS payments you get anyway — so the ePrescribing and generic substitution part is half-way there.

He also talked about Wellpoint’s technology Investment. This is $30m spent by the non-Anthem part of Wellpoint, (CA, GA, MS and WI) which offered free technology to 25,000 doctors in those states. 19,000 accepted –6,000 told them to go fish. For those that wanted ePrescibing Wellpoint gave them Allscripts or Zixcorp and paid for it for a year.  For the rest they gave them a Dell desktop and connected them to a clearing house. 86% went for the desktop, only 14% took the ePrescribing package for which Wellpoint comped the $59 a month cost for a year. It seems that the rest were just getting a free computer to give to Betty in the front office and that that part of the giveaway had little value other than to make the physicians a little happier.

Of the 2700 who took the ePrescribing package, 2,000 registered on the system last year but only about 200 are using it with 30,000 Rxs submitted electronically.  This program started in Fall 2004 so there is indeed some ramp-up to go, but in general, as Wellpoint’s chairman Len Schaeffer said,  "free isn’t cheap enough". They are though doing a formal evaluation of both sides of the deal which will be available eventually.

The initial conclusion is that ePrescribing is not high on the radar screens of physicians, and getting to the small provider is a significant challenge.

Wellpoint  did on another study in the northeast (Barbaro’s region) with a big MSGP (26 docs) to whom they gave an ePrescribing system. They found that with an ePrescribing system costs per Rx went down 2% in the Q3 2003  compared to Q3 2002,  even though the number of scripts written continued to increase. As a control group they used other docs in the same region who’s costs per script went up 6%. Overall the PMPM costs of drugs for the target group was still higher that the control, suggesting that those docs were higher prescribers overall. But lots of other factors were being introduced at the same time. Most importantly they increased their level of generic prescribeing 4%, more than 4 times that of the control group.  Which is a pretty sobering thing for pharma to consider until you realize that something like 30% of scripts written are never filled and presumably eScripts will be filled more or less automatically.

Barbaro’s view is that at some point if providers don’t have the systems to show that are giving value then they will just get less money. But this is going to be a long long haul.

A doc from Colorado somewhat disagreed and says that money would be better spent to get ePocrates to put PBM formularies on their software. He said that it’s just too hard to do ePrescribing without a full EMR.  He thinks that it’ll fit their workflow better.

A tough topic for sure. The next day Mark McClellan from CMS said that ePrescribing will be mandatory for Medicare part D by 2009.  But I’m not sure if that means mandatory for all doctors or just mandatory for the plans to accept eScripts. If it is mandatory for all doctors then we’ve only got three years to sort this out, which basically cannot be done — unless someone can show me another market that went from 5-10% penetration to 100% in three years!

So there’ll plenty more to say about this whole topic in the future.

Meanwhile I didn’t go but here’s the slides from a presentation about Kaiser’s EMR.

There’ll be more about McLellan either later today or tomorrow, but the hotel didnt have Wi-Fi so I wrote my notes by hand!! And typing them up later loses out to going to see the replay of today’s Chelsea v Barcelona Champions League game!

UPDATE: I am delighted to report that Chelsea beat Barcelona 4-2 in one of the better European Chanmpionship games of all time, going through to the next round.

BLOGS and BLOGGING: Is Joe interesting

I met a leading luminary from America’s physician world yesterday, and he questioned whether (at least one of) the "Interesting health care people" list I have in my right hand blog roll were really interesting.  So should I change it to "somewhat interesting health care people"? Chortle, chortle.

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