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POLICY: France faces health budget crunch

Just to follow up on the news from the UK last week, there’s a report out from the French government suggesting that they might both charge more for prescriptions and increase the payroll tax that supports health care.  The government’s fear is that it may end up with a yearly deficit of 29 billion Euros (apprx. $35 bill) by 2010.  France is supposed to be keeping its budget deficit to a specified amount as part of a wider EU agreement (although neither it nor Germany has managed that so far!) and health care accounts for 20% of the overall deficit. 

In France drugs account for more than 20% of health care spending (compared to less than 10% in the US) and so reducing Rx consumption is a likely target of cost cutting.  Incidentally the only place that uses more prescription drugs per capita than France is Japan, where doctors traditionally make most of their incomes dispensing drugs–a little like oncologists in the US, who are now finding that source of income being switched off.

QUALITY QUICKIE: Letter from England, (with UPDATE Tues)

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UPDATE: Don Johnson and I are having a friendly spat about the real cost of health care in Europe and another about the uninsured in the new comments section of The Business Word.  I hope that Don keeps support for his comments section up and that you’ll join me in commenting there. (I’m barely able to keep my blogging up, so no comments here for a while yet).

I’ve been in the UK for a few days and thought that it would be appropriate to give you some impressions of what I’ve been hearing about the state of health care over here. One of the most noticeable factors is that we’re not in France. The BBC reported last night that the French health service was about to have a doctors’ and pharmacists’ strike because of threats to reduce government finance of the system there.  The BBC reported with some incredulity that any French person can get any operation they like any time for free, but did point out that the French pay 30% more overall for their system, and that (stop me if you’ve heard this tune before) costs were going up faster than the economy can afford it, etc, etc.

The UK is also increasing its rate of health expenditure from what used to be a very miserly 5.5% of GDP on the way to 7-ish%.  In some ways they are having capacity constraints, with the result that some GP positions in London are vacant, and some patients are being sent to France for surgery to reduce waiting lists.  That’s possible because these days funding for primary (including Rx) and secondary care is organized via Primary Care Trusts (PCTs) which buy (or "commission" in New Labour-speak) hospital services from Trust Hospitals.  Although this might seem like the basis of a competitive market, in fact a PCT tends to cover virtually all the residents of one town, and the hospitals they purchase from usually have a catchment area that’s about the same size as the PCT.  In other words there’s more or less a single buyer (that looks something like a staff-model HMO) and a single seller (the local tertiary care hospital) — and there’s not real money flowing between them. Within the PCTs, the primary care is delivered by notionally independent GP practices, who behave much as they always did — although the minority which were "fundholders" under the previous reform environment probably have less control over hospital purchasing than the used to.

The most interesting development is the move towards what might be called intermediate risk sharing for chronic disease management. Starting in April 2004, GP practices will be putting up to one third of their revenues at risk, and be able to earn 1050 points by hitting a number of targets in certain therapeutic areas.  Each point will start off being worth up to 75GBP but will go up to 120GBP.  In other words each GP may have up to 120,000 GBP at risk for their practice, which may wind up to 30-40,000 GBP per doctor in real money. There are ten chronic disease states being targeted, many of them surrounding cardiac care, with some 75 metrics being measured. The measurement of the interventions, which are all the standard things of keeping the heart patients on the right drugs, making sure the diabetics get their eye exams, etc, etc, are being done from the information systems of the GPs themselves.  But this isn’t the gong show it would be in the US as by now the vast majority of GP practices have got primary care EMRs, and most GPs are taking electronic notes during consultations.

To this point, many GPs have just been coding office visits with electronic diagnoses that are the easiest to input rather than the most accurate (i.e. coding all visits from diabetics the same).  They don’t get paid any differently for different codes (unlike the US) so convenience had been the driving factor. Most of the GPs I talked with are fairly confident that the add-ons required, such as alerts to contact patients to make sure they’ve come in for an annual exam, or alerts to remind the GP in the middle of the consult that the hypertensive patient hasn’t had a blood pressure test, can be (or already have been) added to their systems – and that’s where they’re focusing the most effort. There’s also a presumption that some of the smaller one or two doctor GP practices with only a couple of thousand patients will merge to get better IT IT and admin support. Overall there’s some optimism about the system, as reflected in this American assesment from UCLA’s Paul Shekelle.

It’s also interesting to note that in the absence of the completion of the huge EMR in the sky projects that the government just awarded contracts for, the UK is already far ahead of the US in primary care IT.  However, this doesn’t really spread over to the hospital side.  In fact frequently the communication between GP and Hospital specialist breaks down (does this sound familiar?) and a patient may be put on a drug in the hospital and the GP either not be informed about it, or take them off it when they come for the follow up visit. As the GPs currently control their own drug budget they’ve been somewhat incented to under-prescribe – any savings there can be used in the rest of the practice to buy new computers, nicer chairs for the waiting room, etc. Additionally the end points that GPs are going to be rewarded on are based on intermediate outcomes, not on hospital measures.  So for example, getting the % of at-risk patients on statins up above a certain number will be rewarded and it’s just assumed that this will reduce costs down the line and in the hospital.  But at present no one’s counting and the information systems aren’t really able to talk to each other about it. However within the PCTs there are already guidelines that many GPs (are at least trying to) follow willingly, even though they’re paper based, and there is a system of clinical consultation over local guidelines at the PCT level itself.  As well as the NICE (national institute for clinical excellence) which creates national guidelines for technology and drugs based on cost-effectiveness analysis.

Additionally there was great familiarity with the Kaiser system, and the NHS has done a series of comparisons between the two, which in part inspired the new contracting system by showing that the lower use of hospital care and greater emphasis on overall patient management at Kaiser led to better and more cost-effective care.  But many people I talked to were aghast when I described the state of IT in the typical American doctors office – they just assumed that the rich Yanks must be well ahead of them!

INDUSTRY: Healthsouth soap opera reaches ridiculous stage

And just when you thought the Healthsouth mess couldnt get any more bizarre, the new management have decided that the fraud was worse than they were letting on, $4Bn rather than $2.5Bn.  One "victim" is ex-child actor, star of the Wonder Years, Jason Hervey who was hired as a PR slack by Scrushy, in a more than bizarre move.  He was given a 3 year deal in 2002 at a mere $300,000 a year and then fired last March. He was offered either a lump sum buy-out or could keep collecting every two weeks which he did.  Well funnily enough last November the checks stopped coming and now he’s gone to court to get them to resume. 

For you soccer fans this reminds me of the obscure tale of Winston Bogarde, a one time Dutch international who’s been on the payroll at Chelsea FC in London at a mere $2.5 million a year and has not featured in any first team or even reserve team game in 3 years.  No one at the club remembers why they signed him, and the coach and general manager at the time both claim the other one signed him without their knowledge, but so long as he clocks into training once a week, there’d nothing they can do other than hand over the cash…..

Perhaps the only way either Chelsea or Healthsouth can get out of their obligations is to declare Chapter 11.  Chelsea was bought by Russian billionaire Roman Abramovitch last summer and has been spending money like a drunken sailor on new players ever since, so their chances of fooling a judge are limited.  Healthsouth? Well I’m not so sure…….

PBMs: More litigation attacks on PBM behavior, leads to longer term doubts.

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I’ve reported before on the suits against Caremark and Medco for all kinds of alleged shenanigans in drug pricing, rebates and other activities kept away from their clients’ eyes.  There’s a bumper crop of news this week about the same topics.  The latest version of Government Health News reports that the attorney general of Ohio has jumped in with his own suit accusing Medco of slanting drug purchases towards its (former) corporate parent, Merck. Meanwhile 2 unions in New York State are accusing Express Scripts of keeping rebates that it didn’t tell them about. Finally another study in the Journal of the American Pharmacists Association reports that PBMs have been overcharging on the spread between wholesale and customer prices for generic drugs.

It’s been fairly common knowledge around the drug industry for many years that not only are PBMs getting rebates to influence which drugs end up on their formulary, but that much if not most of the rebate money doesn’t go all the way back to the clients, and in fact is a fairly substantial chunk of the PBMs’ bottom lines. As I’ve opined before, whether or not it’s a legitimate business practice as the PBMs claim, when Medicare becomes the client that type of behavior is not going to survive the scrutiny of any even half-hearted Congressional investigation.  At that point I find it hard to see how PBMs become little more than claims processors, and I’d expect their PE ratios to fall to match.  The question is whether they can increase their revenues enough by adding the volume from Medicare clients to allow their stock prices at least to tread water.  I doubt it, but it’ll be an interesting subtext in the implementation of NAIM.

POLICY: Notes from my wonderings on Medicare

In New York last week I had a great visit with my old colleagues at Harris. Humphrey Taylor had some new data showing that flu vaccinations don’t seem to work. Meanwhile Bob Leitman broadly agreed with me that we can’t expect anything much out of the next Congress no matter who wins the Presidency as, there may be as many as 5 Senate seats in the south that go over to the Republicans, and so the Congress itself will be to the right of this one. However, by 2008 things may be different. By then the TROOP and the donut hole will be familiar to the NASCAR dads (the southern males who vote Republican but economically should be Democrats).  Also, by then the first tranche of the baby-boomers will be retired (if they can afford it) and two years away from Medicare.  And they will be finding the individual insurance market increasingly difficult to deal with.  Meanwhile Medicare will be entering its most costly phase–the run up to 2020 when the peak of the baby boom hits 65. At that point wider appetite for reform financially from the fiscal hawks and from the baby busters who’ll be paying for this may meet the interests of the soon to be Medicare recipients who don’t like the benefits the way they are.  Some where in there is the subject of the real debate and therefore the seeds of a real compromise for a workable solution.  Maybe.

NOTE: Lite today

I’m travelling today and tomorrow.  There may be something wonderful written on the plane, there may be not.  So please check on Friday but don’t hold it against me if you don’t see anything till Monday. Thanks. Matthew

POLICY: 1991 redux? NY Times discovers health care crisis, Democrats response to it

Apparently there’s a health care crisis going on. 43 odd million uninsured, (that’s at any one time–25 million basically permanently 80 million for some substantial time in any 4 year period), costs going through the roof (premiums up 8% over inflation in 2002 and more last year), and Medicaid coming under the knife. Oh, and seniors hate the NAIM (new and improved Medicare). The NY Times reports that the Democrats all have their health care plans and are taking them seriously. However, there are two minor differences between 2004-6 and 1991-4:

a) With the exception of the three outsiders’ single payer plan, none of the "main" Demo candidates proposals gets to universal coverage.  Don’t forget these are proposals.  And as you know any Presidential proposal will get watered down over the course of the negotiations in the Congress–especially in a Republican Congress.  So if, to pick on one suspect, Dr. Dean’s proposal will take us from 86% insured to 92% insured, the actual result may be to go from 86% insured to 91% insured–and that he’d regard as a victory.  It’s impact on the hard core uninsured and the providers who have to deal with them would be close to unnoticeable.

b) It’s not 1991.  We haven’t just won the cold war and can now concentrate on the peace time economy.  We’re involved in a never-ending "war" that whatever your view on it will be the main event in elections form now to 2006 and beyond.  Health care will be a poor second till the mass of NASCAR dads (the ones in the South who economically should be Democrats but culturally are conservatives and decide Presidential elections) get closer to retirement age and notice that they might need Medicare and Social Security.

In the meantime Bush is pushing his $89Bn tax break for the uninsured to buy their own insurance really hard.  I think he’s mentioned it twice in three years!

PHARMA/POLICY: New word for the day

Just a quick post as I’m traveling all day today. Yesterday I heard a new Medicare term to do with NAIM ("New and Improved Medicare"). The word is TROOP, which stands for "True Out of Pocket"costs. Those are the costs that will actually be recorded against your deductible and the donut hole for your yet-to-come Medicare drug coverage, and as you might suspect, it may not included everything you might think!

PHARMA: Potential blockbuster drugs to watch in ’04

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CBS marketwatch has an interesting list of new blockbuster drugs to watch for in ’04. One of the blockbusters is Caduet, an interesting combo pill from Pfizer that combines Novarsc and Lipitor for both hypertension and high cholesterol. This helps patients by making it easier for those with multiple conditions to remain compliant. But as was noted by the Industry Veteran last Friday, the development of the combo pill also gives pharma companies a chance to raise prices.  You can expect that the payers may not be so interested in improving the ease of patients, but will use three tier formularies and other tools to increasingly push the decision over spending extra for an easier to use product down to the consumer.

PHARMA: Big pharma gets aggressive over pricing

Two of my favorite contributors both have found me interesting stories about pharma company tactics today.  Jane Sarasohn Kahn sent me an article about the ongoing US-Australia talks on drug pricing.  Recall that the Aussies joined us in invading Iraq because they were promised in a nudge-nudge wink-wink way a free trade deal which would allow their agricultural products into the US market. However, fresh from victory in the Medicare drug coverage arena, the US pharmas a going after price "discounting" by governments abroad.  (For background info look at this latest edition of the Pfizer sponsored Health Politics which basically trots out Mark Pauly’s not entirely untrue line that Canadian drugs aren’t any cheaper than US drugs overall when you factor in that fact that they don’t use so many generics and don’t allow access to the some of the newest and most expensive drugs). As part of the Australian negotiations things are getting a little heated. The Australian (which is the pretty unsuccessful result of Murdoch’s attempt to create a highbrow national paper there) wrote that

    US drug lobbyists were peddling misinformation about Australia’s medicine subsidy scheme to secure a better deal under a free trade agreement, federal Health Minister Tony Abbott warned a delegation from Washington yesterday.

    During a meeting with a powerful US congressional delegation yesterday morning, Mr Abbott also said the Australian Government would not change the "basic architecture" of the $5.8 billion-a-year Pharmaceutical Benefits Scheme to secure a trade deal. But he left open the prospect of other concessions to multinational drug companies, saying he would be happy to talk with them about demands for greater transparency. After the talks with Acting Prime Minister John Anderson and eight influential Republican congressmen in Sydney yesterday, Mr Abbott accused drug lobbyists of waging a dishonest campaign against the scheme. "Misleading information is being peddled in Washington," he said in a statement. "The PBS is not a rationing system but a subsidy system. The PBS does not deny access to US drugs but treats them exactly the same as drugs made in Australia or elsewhere."

Now despite the party name (which harks back to the old European meaning of liberal not its American derviation) the Aussies have a very right wing government in power by all but US standards. (Randomly enough I’m a friend of Tony Abbot’s sister who’s political views are somewhat pinkish and despite the fact her brother is the rising star of the Aussie Liberal party and a likely future Prime Minister, she basically thinks he’s a right wing nut!) So if the Aussies feel that they can’t sacrifice their drug pricing system despite the huge carrot of free-trade in agriculture that the US is dangling, there’s no chance of the Europeans doing so.

Meanwhile, the Industry Veteran sends me this story about Abbot’s huge price increase in Novir, its protease inhibitor which is used as a component of many anti-viral HIV regimen. Basically Abbot has increased the price of a drug five-fold that is used in combination with its competitors anti-virals, but if you take Novir in a combo form with Abbot’s new protease inhibitor Kaletra, it’s now cheaper than taking it separately with the competitors’ drugs. The Seattle Times reports

    Abbott is pricing Norvir as though it is a "full component" in the drug cocktail, complained Shalit. "But it’s not being used for its activity against the virus — it’s used as a booster for the other drugs." While Abbott vigorously denies it, Shalit and others believe the Norvir price increase was aimed at Abbott’s competition. In essence, Shalit said, increasing Norvir’s price raises the cost of taking Abbott’s competitors’ drugs used in combination therapy. That could push patients toward Abbott’s newer drug, Kaletra, a combination drug with Norvir built in. With the Norvir price increase, Kaletra’s competition has become more expensive than Kaletra, approved by the Food and Drug Administration in 2000.

    In their letter to Abbott, the local doctors also expressed worry that the increased cost of Norvir would have a chilling effect on development of other drugs designed to work with its boosting power; at least one such drug is now being tested in Germany.

The Industry Veteran comments

    Here’s an ominous trend that I see as more pervasive than just the HIV area. Big Pharma will seek to extend patent protection and up-sell patients by exorbitantly raising the price of single-compound products, thereby coercing people onto fixed-dose combinations (one pill containing two or more compounds) that contain the unconscionably priced compound. Watch for this trend in (y)our favorite category: the statins.

In any event both these stories prove that big pharma, conscious of its potential problems with future drying pipelines, is going to fight hard to maintain its profits and protect its turf.  That’s to be expected and it is also part of their fiduciary duty which, lest we forget is not to Canadians, Australians or AIDS patients, but to their shareholders.  The question is will this type of behavior cross the line and cause sufficient resentment that politicians bring a backlash against them. That may yet happen in their incredibly unpopular opposition to Canadian imports.

Then again there is the other question that Jane posed in her post here a month or two back. She wrote

    Pharmas are looking to biotech for new formulations, but they’re also looking to smaller pharmas too for licensing deals. This will be important over the next few years. Obviously, biotech will be important in the longer term, but the juries are still out on so many very expensive drugs. We will be hitting the wall on who is going to pay for those expensive bio drugs, and I anticipate that will be a big area of contention. It’s not clear really who will be willing to pay for innovation.

Jane’s follow up goes to the heart of the "how much will who pay, and be able to pay?" question.

    In today’s news, I see that the small pharma Trimeris based in NC which produces the $20K/year drug, Fuzeon, for HIV/AIDS, is now laying off and looking like it could close shop…for a few weeks, literally, a few payers last year said they’d be willing to pay for such an expensive HIV drug. However, as I recently told one of my clients who is big in HIV, that’s one disease state where that high cost just won’t get rationalized….now an expensive prostate cancer drug used by rich old white (mostly) men, sure…but even $20K a year for that wouldn’t be chronically taken virtually ‘forever.’ Some discussions are afoot about whether we have "enough" innovation for now.

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