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POLICY: Seniors continue to oppose new Medicare law. With UPDATE

Harvard’s Bob Blendon (a colleague of mine from my IFTF and Harris days), has new polling research out sponsored by the Kaiser Family Foundation showing that two thirds of seniors view the Medicare Modernization Act unfavorably. Here’s the end implication:

Nearly three in ten seniors and people with disabilities on Medicare say the passage of the new law will have an effect on their vote for president, and an even higher share– nearly four in ten–say it will have an effect on their vote for Congress in November. More people say that the law will make them more likely to vote for John Kerry and the Democrats than for President George W. Bush and the Republicans.

And here are some more details, which should ensure a huge amount of ads highlighting the shortcomings of the law from the Democrats filling the airwaves of Florida and Pennsylvania.

Nearly three in ten people on Medicare (28%) say that the passage of the Medicare law will have an effect on their vote for president. More than four in ten of those who say the new law will affect their vote (44%, or 12% of people on Medicare overall) say it will make them more likely to vote for John Kerry, while 18% of this group (5% of people on Medicare overall) say it will make them more likely to vote for George Bush.

Nearly four in ten (38%) say the passage of the law will have an effect on their vote for Congress. About half of those who say the law will affect their vote (53%, or 20% of people on Medicare overall) say it will make them more likely to vote for a Democrat, while 21% of this group (8% of people on Medicare overall) say it will make them more likely to vote for a Republican. When it comes to handling Medicare prescription drug benefits, people on Medicare are nearly evenly divided on whether they trust John Kerry (39%) or President Bush (34%) more, while about one in ten (11%) say they trust neither or trust both equally. Not surprisingly, Republicans (76%) are more likely to say they trust President Bush more on the issue, while Democrats (67%) are more likely to say they trust John Kerry.

UPDATE: This survey has sure gotten alot of press, which must make Drew Altman and the crowd at Kaiser FF happy. It has two articles in the NY Times, plus it was a lead on NPR last night and might even have made the network news (I don’t tend to watch those but judging from the DTC drug ads many seniors do!) This NY Times article points out the obvious–the elderly are a vulnerable Republican voting block. They vote proportionally more than any other group, and they tend to vote on health care. Last time around white seniors voted 52 to 47 for Bush partly because he promised drug coverage (as did Gore) but partly because they were the group most appalled by blowjobs in the Oval Office. Remember Bush promising to restore "Honor and Decency" to the White House? Well I guess if that only means no blowjobs in the Oval Office then that’s Mission Accomplished. But when seniors have got something serious to vote about like the Iraq war and drug reimportation — both of which the elderly oppose–then "Honor and Decency" may not be enough to keep them happy.

PHARMA: The Industry Veteran on Polypharmacy in Psychiatry

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Yesterday’s WSJ had an article on the increasing use of polypharmacy in psychiatric treatment of bi-polar disorder, depression and schizophrenia. It’s controversial because there have been no clinical trials to prove its value, and due to the nature of those conditions it can be hard to measure outcomes which in any case may vary dramatically between different patients. As the article is behind a firewall I’m going to quote somewhat liberally from it:

Psychiatrists are increasingly crafting drug cocktails of multiple medicines to treat depression, bipolar disorder and schizophrenia. The approach, called polypharmacy," aims to help people who don’t respond to a single drug by putting them on several drugs that target different brain chemicals. The approach — driven in part by the shortcomings of many available medications — is psychiatry’s answer to HIV/AIDS drug cocktails and combinations of cancer drugs. But there are some key differences. Unlike HIV and cancer — whose underlying cell biology is fairly well understood and that have been the subject of clinical trials involving drug combinations — the causes of mental illness remain largely a mystery. Little research has been done about how to administer polypharmacy or whether it even works in some cases. Multiple drugs also mean multiple side effects — and multiple prescription bills. Doctors arrive at the right mix by tinkering with a sequence of different drugs based on past experiences, word of mouth and drug-company marketing that informs them about the strengths and weaknesses of each drug.

(snip)

Some psychiatrists question whether more drugs are necessarily better. Gabor Keitner, professor of Psychiatry and Human Behavior at Brown University in Providence, R.I., thinks polypharmacy has gone too far. Patients are plied for years with a dizzying sequence of drugs that have side effects ranging from insomnia to lack of libido to weight gain. "I think we are overmedicating people," he says. Dr. Keitner, who directs the inpatient mood-disorder clinic at Rhode Island Hospital, also worries that patients are getting the false hope that some magic combination of drugs will cure them. It may be better, Dr. Keitner says, to teach patients how to manage their conditions and emphasize continuing therapy. "This is leading us down a path that may not be good for patients or the profession," he says.

Still, for many, the cocktails provide long sought-after relief. Noreen Fraser, a 50-year-old mother of two from Los Angeles, was treated for depression with multiple drugs during her three-year battle with breast cancer. The powerful cancer drugs she took abruptly halted her body’s production of estrogen, sending the normally animated television producer into a deep depression. "I couldn’t even help my children with their homework," Ms. Fraser said. Her psychiatrist, Andy Leuchter of the UCLA Neuropsychiatric Institute, tried combining two antidepressants. That worked only for a while. Then last fall, Dr. Leuchter added a low dose of the antipsychotic medication, Zyprexa, into the mix. Within two days, Ms. Fraser felt better than she had in years. "It was like a cloud lifted," she said.

(snip)

Using multiple drugs to treat mental illnesses has become controversial partly because of the cost involved — especially with schizophrenia. The standard therapy for schizophrenia today is the use of "atypical" antipsychotics, which have milder side effects than older drugs, but are relatively expensive. A month’s worth of Bristol-Myers Squibb Co.’s atypical antipsychotic Abilify, for instance, costs $352 whereas generic clozapine, an older drug, costs $152. If a schizophrenic patient doesn’t improve on one drug alone, doctors may add another atypical antipsychotic or one of the older "typical" drugs. In some states, public-health programs have balked at paying for combinations of psychiatric drugs without evidence that the treatment actually works.

Insight on how to use combinations of drugs to treat resistant cases of depression may be provided by a large government-funded trial just completed that tested various prescribing strategies. But results of the trial, conducted with 4,000 depressed people in 13 states, aren’t expected until May 2005.

Given his moderate and understated views on the medical profession and its relationship with pharma manufacturers, regular THCB readers may be surprised to know that Industry Veteran has his suspicions about the science and the marketing behind the new polypharmacy.

    1. The cocktail approach to therapy represents an emerging paradigm in psychiatry that a growing number of clinicians do not reserve as merely a last measure. At a recent meeting of the American Psychiatric Association, a clinical investigator gave me a synopsis of his thinking. "In neuropsychiatry," he explained, "since anything can cause anything, it’s wise to use everything for everything." In other words, throw as much s- – – on the wall as you can and see what sticks.
    2. Advocates of early cocktailing not only lack an understanding of the pharmacological basis for their polypharmacy regimens, some even disparage such basic science and consider it an after-thought or a fig leaf. At various times, cocktailing exponents have told me that medical science need not advance "in textbook fashion" by moving from basic scientific understanding to clinical applications. If a drug or a drug combination appears to offer clinical benefit, according to this worldview, then the bench science guys can retrofit a mechanism to provide a soothing rationale for the clinicians.
    3. More than a few colleagues have whispered to me their opinions that the cocktail approach in psychiatry represents a combined effort by psychiatrists and drug companies to grow their businesses. Entrepreneurial psychiatrists, frustrated by limited reimbursements and a median income that lags behind most of other specialties, promote cocktailing to create a niche for themselves as "medication specialists" (they actually use that term on their business cards). The drug companies subsidize this effort as a means of developing new, frequently off-label markets for their products.

It’s doubtlessly true that some desperate souls have received substantial benefits from psychiatric drug cocktails after failing to obtain relief from more conventional therapies. I am always suspicious, however, when bald-faced greed concocts a new therapy in an environment where no one guards the guardians.

PHARMA: Marcia Angell makes more waves

Marcia Angell has been on a tear lately promoting her new book. She has a brutal interview in the LA Times which essentially summarizes all the complaints about drug companies made in the last decade. Here’s a sample:

Conflicts of interest are rampant. When the New England Journal of Medicine published a study of antidepressants, we didn’t have room to print all the authors’ conflict-of-interest disclosures. We had to refer people to the website. I wrote an editorial for the journal, titled "Is Academic Medicine for Sale?" Someone wrote a letter to the editor that answered the question, "No. The current owner is very happy with it." That sums up the situation nicely.

To my mind pharma companies need to understand two very important points here. First, while a few academics have been complaining about pharma company practices for several years, this is the first time that I remember one book about pharma having such a sustained impact. Angell has already been on 60 Minutes, this interview is not in some minor blog or academic journal, it’s in the main paper in the nation’s second largest metro area, and she’s also had a recent column in the Financial Times. And this is at a time when the reputation of pharma companies is already heading into uncharted low territory amongst the public. Second, pharma needs to both start making some new arguments about what it’s doing and how it’s trying to improve. Big pharma also needs to consider what life might be like in a world where HHS officials have not only decided that they can bargain about the price of the drugs Medicare is paying for, but one in which they’ve read Angell’s book. This is not necessarily a doomsday scenario, but a little bit of "what if" scenario planning wouldn’t hurt big pharma right now.

EMPLOYERS: Halliburton sues retirees on health coverage

Last week every liberal’s favorite company, oil services supplier, all-round US Army replacement and DOD no-bid contract winner Halliburton, managed to squeak out (more or less) of an SEC investigation into accounting shenanigans that kept its stock price high while it was merging with Dresser in the late 1990s. Several commentators thought that the SEC let them off very lightly and, for reasons that are unclear (but can be guessed at by us conspiracy theorists who note that the SEC head was appointed by a Mr G.Dubya Bush), the SEC decided not to allot any legal blame to Halliburton’s CEO at the time, a Mr R. Cheney. Mr R. Cheney has a close political relationship with several people called Bush, and also serves in some kind of role in the current Administration. He does though remain on Halliburton’s payroll receiving somewhere between $150,000 and $600,000 a year in something called "deferred" compensation. If you’re interested in this ruling you might want to read liberal blogger Billmon’s article on the subject.

Halliburton though is engaged in another potential scandal that may be of more interest to my health care audience. They are launching a pre-emptive strike (another Cheney legacy no doubt) against three retirees who complained about being dumped out of their company-sponsored health coverage so that the retirees have to appear in a court in a state of Halliburton’s choosing, and so that Halliburton can get its side of the story out first. The company’s argument is that they are entitled to change their retirees’ coverage.

This may be a (rare) case where Halliburton is not completely in the wrong, although by suing their own retirees, one of whom is the former VP of HR at Dresser, they continue to prove that PR is not their strong suit. While the promise to keep the health benefits may have been rescinded and while that decision may be morally dubious, legally it appears that corporations can dramatically reduce benefits. For example United Airlines has recently basically cancelled all its contributions to pension and health benefits for retirees (for an non-unbiased version of that story, see here) In any case this is a forerunner of what will happen in the next few years as companies start removing their health insurance benefits for retirees under 65 and the wrap-around Medi-gap policies, which typically provide drug coverage for their retirees over 65. The latter will of course be encouraged by the new Medicare drug benefit, despite the fairly substantial bribes subsidies in the legislation which encourage employers not to cut this benefit.

The last laugh of course is that the purchase of Dresser brought with it a huge unknown unknown (as Mr Cheney’s friend and colleague Mr Rumsfeld might have said)– a huge asbestos liability which nearly took the company down with it.

PHARMA: A bizzaro world view on reimportation

Roger Pilon from Cato, the thinking man’s libertarian think-tank (as opposed to AEI or Heritage) last week, decided that the US should give up on the reimportation ban. The basic reasoning is that it won’t be a big deal as the drug companies won’t let too much inventory go overseas, and if we let importation happen, the American market will force price rises abroad.video of this debate between Cato’s Pilon in favor of reimportation and an AEI staffer Jack Calfee who opposes it. Almost a doppler world here in which the AEI scholar is arguing that price controls are OK in poor countries because they keep drugs available in poor countries. Reimportation would, according to both of these "free-marketers", see higher prices abroad. They are of course both opposed to price controls here–such as happen abroad. But what that means in real life is monopsony purchasing by the government. That could happen here very easily by CMS, the VA and the states agreeing to negotiate with the drug companies, as the VA does and Medicaid sort of does. This type of "price control," PhRMA tells us all the time, would ensure that R&D for pharma would collapse, and we’d all be dying in the streets. Both Pilon and his AEI counterpart note that as government’s share of the drug market increases, these "price negotiations" are likely to happen anyway.

You can see a long

No one mentions the obvious question which is, in which industry would people invest their money if margins in pharma went down slightly? Seems to me that a blockbuster is a blockbuster and will find investment capital whether it’s returning 30% or 20% net margins. Of course that would mean that reductions in costs at pharma companies would have to happen somewhere, and the obvious answers are from the two biggest slices of the revenue pie at pharma companies–those being sales & marketing and profits. (R&D is the third biggest number). It’s also worth noting that many industries such as high-tech and autos spend large amounts on R&D without either patent protections or such high margins. And yet they manage to bring out new products all the time at continually lower prices.

QUALITY: Millenson demands a shock to the system

Writing an Op-Ed in USA Today, Michael Millenson says that making a national error reporting system voluntary won’t work. The Senate voted 98-0 to create such a system last week and USA Today had an editorial saying that it was a good idea, but should have gone further. In some ways that such articles appear in the mainstream press shows the great progress since the IOM issued the To Err is Human report, given organized medicine’s ability over the previous century to quiet the incipient debate on the medical error and quality topic, (as detailed by Millenson in the wonderful Demanding Medical Excellence). But the IOM set out a goal of a reduction in errors of 50% in five years. Well the report was issued 5 years ago next month and no one is pretending that target has been reached (outside of LDS hospital in Salt Lake City, scroll down here to the June 10 entry for more on that)Here’s what Millenson said yesterday:

While voluntarism is valuable, it has been five years since a landmark IOM report made patient safety a public scandal. During that time, doctors and hospitals have not voluntarily organized to stop the preventable deaths and injuries of hundreds of thousands of patients with anything close to the energy used to battle malpractice awards worth hundreds of thousands of dollars.

Doctors and hospital managers are not venal and uncaring. In fact, many care so much that they find it too painful to face up to the commonplace nature of errors. As a result, doctors routinely protest that the patient-safety issue is overblown. I’ve seen it firsthand hundreds of times. If you really believe in systemic change, you have to be willing to shock a lethargic system into abandoning the status quo.

The way to do that is with the mandatory reporting of serious errors. In Minnesota, for example, progressive hospitals supported the mandatory reporting and analysis of 27 serious events, along with appropriate confidentiality and legal ”safe harbor” provisions. Moreover, errors are tabulated and made public each year. Across the U.S., a few courageous hospitals even involve patient representatives in error-prevention panels.

No member of Congress would think of making airline-crash prevention voluntary. Protecting the sick and the vulnerable among us is surely at least as important.

PBMs: Spitzer puts the boot into Express Scripts

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NY A-G Eliot Spitzer continues his swath through the boardrooms of America. He’s piling in on the recent investigations and he comes right out and accuses Express Scripts of fraud.

The suit alleges the company inflated the cost of generic drugs at the expense of New York state’s largest employee health plan, the Empire Plan. It charges the company cheated the state on payments from drug companies that Express Scripts received when negotiating on behalf of New York. Spitzer, who has been probing the company for a year, said the abuses occurred over a five-year period and cost the state $100 million. Also named as defendants were two subsidiaries of Cigna Corp.

“They are using their role as an intermediary to line their own pockets,” he told reporters on a conference call. “They were simply committing fraud, and it cuts to the core of the integrity of the company.” Spitzer said abusive practices are not limited to Express Scripts but are rampant throughout the sector. Pharmacy benefits managers, or PBMs, are brokers that act as middlemen, buying drugs for employers and health plans.

That’s not exactly soft speaking, and it doesn’t augur well for PBMs if they have to administer a Medicare program in 2006 that is being run by a Democratic HHS, with possibly a Justice department overseen by an Attorney-General called Spitzer.

POLICY: HSC confirms that employer-based insurance fell during recession

Given the disarray in the individual insurance market, the latest survey from the Center for Health System Change (here’s the News Release and here’s the longer issue brief) proves that economics is alive and well. There is such a thing as an income effect and a price effect–so if business income/revenue goes down and the price of insurance goes up, well funnily enough a lot less people are going to be getting health insurance from their employers. And somewhere mixed in that is the little nugget that if you don’t have a job any more, as we used to say in England, you have two chances of having an employer provide you with health insurance: No chance and (As this is a family blog. I’ll censor the rest of this remark).girlie-men or no girlie-men, and the other is more people on both sides of the patient-provider relationship discovering how inadequate Medicaid is. Furthermore most of the increase was for children rather than adults, so there was some relative shift in who within families got insurance, but even so public sector insurance rolls expanded for adults too.The Blogging of the President which explains (to my satisfaction at least) where this all will drift to: The reason that eventually we’ll get to some kind of compulsory national health care system is grounded in the fact that for the last hundred years if you (or your employer, or the government if like the elderly you had some power and could force the burden onto other taxpayers ) could not afford insurance, you went without. That meant that the medical system could keep charging as much as it liked because those who couldn’t afford it would be dumped into the safety valve known as uninsurance. In such a system two things eventually will happen.

The number of those with employer-provided insurance fell from 67% in 2001 to 63% in 2003. That fast a fall in that short a space of time is pretty significant, and of course starts to throw many more people into the individual insurance market and/or into uninsurance, which are pretty closely related if you’re sick anyway. This also confirms why health insurance is becoming a bigger and bigger deal on the campaign trail as more people are now more aware that growth in health insurance premiums actually costs them something directly (rather than depresses their incomes indirectly as it has for decades now).

The other thing that has been going on is another expansion of Medicaid, which almost mirrors the huge expansion of Medicaid during the early 1990s recession. The number of people getting insurance from public sources went up by 3%. However, that in turn means two things. One is massive pressure on state budgets,

But the big overall message is that we are moving whether we like it or not into a system where the combination of government programs (including Medicare of course) and individual insurance will eventually overtake the employer-based group insurance that has been the mainstay of the US health insurance "system" (and I use that word very loosely). How fast that transition happens depends somewhat on politics, but eventually those with good health benefits at work will be in the minority.

All of this will increase the eventual pressure that we’ll face as a nation to get to grips with this. In fact I’m going to repeat a para here that I wrote in the comments over at

First, costs which have been allowed to grow without any controls will eventually become too great for those paying the bills (esp. large employers). They will continue to push people out into un or under-insurance, which is exactly what the HSC study is finding.

Second, the number of un or under-insured will become so great and politically powerful, that it will end up creating a compulsory "national insurance" system. That system will shift the burden from employers to the taxpayer, which will coincidentally make the employers happy (and most people too, if international surveys are to be believed..)

And once everyone’s in the system and there’s a direct correlation between taxes and health spending, healthcare spending will come under much tighter control. After all we’re Americans and we hate taxes (so long as levied by government rather than the health care system which calls them premiums).

This happened in the rest of the world between 1945 and 1970. It nearly happened in America in 1993, and it will happen sometime in the next 20-40 years here. This isn’t an ideological argument, it just has to play out that way unless health care costs go downwards over that time, and I hasten to guess that not even Mark (Note: Mark was a previous poster in this thread who hated Canadians and poor people) thinks that will happen.

POLICY/POLITICS: Kerry’s post-convention bounce

Jones the Policy Wonk sends me these post-Convention polling numbers.

Internals from ABC poll post-convention–Kerry went from 3% ahead on healthcare to 19% ahead. (Sorry I can’t figure out an easy way to present this!)

The numbers in order are "Now" then " Pre-convention" then "Net Change" (or bounce)Trust Candidate on These Areas:Health careKerry +19 Kerry +3 Kerry +16TerrorismBush +3 Bush +18 Kerry +15IraqKerry +2 Bush +12 Kerry +14TaxesKerry +6 Bush +6 Kerry +12EducationKerry +13 Kerry +1 Kerry +12EconomyKerry +11 Bush +1 Kerry +12Health careKerry +19 Kerry +3 Kerry +16Int’l relationsKerry +9 NA NAIntelligenceKerry +5 NA NA

So the post convention bounce has the Dems massively up in their domestic strengths and even up on Iraq, Foreign relations and Intelligence. "Terrorism" remains Bush’s sole refuge and amazingly enough we get another terror warning just 2 days after the convention.

It’s hard to divine who’s going to win this thing, and it speaks volumes to the strength of the Republicans corporate/Christian right base that they’re even in the race given the state of the economy. But THCB readers should probably start imagining the possibility of a weaker than Clinton-like Democratic White House and maybe even a narrow majority in the Senate. I’ll be blogging more about that in weeks to come.

Massively off topic–I know that people don’t want to criticize the C-in-C about terrorism and I don’t hold him responsible for 9-11 but surely someone somewhere in the administration or intelligence services should be accountable for the fact that before 2001 Al-Quaeda was easily infiltrated by at least one white American and one white Australian. Yet the CIA and its sister orgs didn’t even bother to try, and we never knew what was coming.

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