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PHARMA/PYSICIANS: United is getting grumpy at the oncology-industrial complex

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While I’ve been focusing on pricking egos in the HBS common room, Greg Pawelski has been keeping vigil on our friends over in the wonderful world of chemo. The main recent development is the FDA issuing a warning about overuse of the anti-anemia drugs Eopgen, Arenesp and Procrit. Amgen (which makes the first two and JVs the latter) is running into problems because of this. Greg believes that things may be worse than that. He wrote to me saying:

Superficially, it sounds like a great expose—greedy clinics/doctors trying to make money by pushing drugs. The New York Times article states that the drugs, given by injection, have been heavily advertised, and there is evidence that they have been overused, in part because oncologists can make money by using more of the drug. That’s not really a new revelation. We’ve been down that road before without much done to change it. According to Dr. John Glaspy, director of UCLA’s Outpatient Oncology Clinic, one complicating factor, experts say, is that oncologists make significant revenue buying cancer drugs from manufacturers and charging patients a higher price for receiving the drugs in their offices. That profit motive could influence some doctors’ decisions. However, patients with anemia, which can cause sluggishness in its early stages and can be fatal in advanced phases, can get blood transfusions, typically every few weeks, instead of using EPO.
 

Could it be that increased numbers of red cells deliver more oxygen to the tumor cells and thereby increase their activity across the board, including with respect to invasion, proliferation, and metastasis? On one hand they’re developing drugs to halt and reverse angiogenesis while on the other hand they’re helping the tumor to obtain more oxygen with existing vasculature. And nobody in charge foresaw that? Amazing how they can apply differing standards for proof or benefit when profit is involved.

Whether or not there’s any truth in that it’s clear that bigger guns than Greg’s are being aimed at the issue. And one such gun belongs to United Healthcare which has found some pretty disquieting things about the use of some big time biotech drugs including Epogen and Herceptin among its cancer patients. Lee Newcomer, United’s ex-Senior Medical Director (but still an employee) told a meeting last week:

In reviewing records of patients who were prescribed the drug erythropoietin — an expensive agent that boosts blood supply in patients with anemia — <snip> 44 percent of those patients had blood work-ups that would indicate they were not anemic. Last year at the NCCN meeting, Newcomer also cited the use of the new breast cancer drug tratuzumab, sold as Herceptin, which has been found to be helpful in a group of women with breast cancer that overexpresses a certain gene known as HER2. The drug is ineffective in women with normal levels of HER2, yet Newcomer said about 12 percent of drug orders — which costs thousands of dollars per treatment — were for women who tested negative for HER2 overexpression.

So right there, real questions abut the inappropriate overuse of the two most popular biotech drugs. But that’s not all. What about overuse of other drugs that may also be innapropriate, but that we’re not so sure about?

Newcomer also said that, when he scrutinized prescribing habits for treatment of patients with pancreatic cancer, "we had doctors writing prescriptions for 188 different combinations of treatments, yet we know that there are only two drugs that have any activity against that disease."

<snip>

Newcomer said that one of the newest biological targeted agents, bevacizumab, sold under the trade name Avastin, which is rapidly being included in numerous drug cocktails because it has been shown to extend survival in diseases such as colon cancer, can cost as much as $47,000 a year for one person. "But that doesn’t explain its true cost," Newcomer said. "We know that Avastin improves outcomes in about 20 percent of patients, but we have no idea which cancer patients will benefit from a course of treatment." According to his calculation, it costs $354,000 per year of life extended with Avastin.

And of course, there’s a message in all this for Pharma and the Oncology-Industrial Complex.

Newcomer and other panelists said that unless the prices of the drugs are controlled, a major backlash against the pharmaceutical industry is brewing.

HEALTH PLANS: KP’s Halvorson talks–Merlin responds,and I comment

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Things Halvorson said….

In his remarks to (video, no transcript yet) The Commonwealth Club as interviewed by Chris Rauber, who was being rather too nice—although that’s mostly the fault of the stupid written Q&A format the Commonwealth Club uses (You’d think that something vaguely modeled on the UK system would grok the concept of a follow-up question), KP CEO George Halvorson said a few interesting things:

“One of the things we need in American health care is an extremely high level of transparency” (more on that later George!)

“Any time you get to a pure single payer system you get a health care system that rations <snip> if you want a good look at single payer look at the medical systems in our prisons.” I agree with him in his specifics about transparency and how it would be better to have a system with providers competing properly with better information, but with that type of rhetoric is his next job at NCPA or at PRI? C’mon George! Every health care system rations—something John Goodman is actually right about. The question is, how is it done? Just accusing single payer systems of rationing and actually bringing up the erroneous bogeyman of Canadian patients crossing the border puts Halvorson in a camp of wingnuts with whom he ought not to be associating himself.

And as for that transplant program. “It was an excellent program” but on the administration of the list “we just screwed up.” Methinks that David Merlin, the fired administrator of that program and the source of the LA Times story does not agree. Here’s what he said in response in a letter to the SF Business Times today:

Whistleblower: Kaiser’s kidney ills not tied to CEO’s absenceAs the person who exposed the Kaiser kidney transplant program tragedy to state and federal officials and the media, I¹m certain the majority of Kaiser kidney patients are as insulted as I by George Halvorson¹s attempt to portray KP¹s unwillingness to speak up and/or take responsibility due to his six-week absence. KP¹s transplant program had been in operation over 18 months prior to his hospitalization in April 2006. The massive clinical and administrative failures had been identified by Kaiser senior officials long before this. Around May of 2005, a majority of the 48 northern California Kaiser nephrologists (kidney specialists) called an emergency meeting of senior KP physicians (including Robbie Pearl, M.D., CEO of the 6,000 member TPMG physician group) and demanded the fledgling Kaiser kidney program be shut down due to overwhelming concerns of patient neglect and associated health issues and that all 2000-plus patients be sent back to UCSF and UC-Davis Medical Centers.These problems didn’t suddenly surface at the time Halvorson became ill. His comment that the kidney crisis was kept from him during his six-week recuperation rings hollow and his assertion that United Network for Organ Sharing thought Kaiser was transferring one patient, and not 2,000, is both ridiculous and irrelevant. Kaiser (TPMG) doctors were responsible for the day-to-day care of these patients, not UNOS.Kaiser has attempted to portray their internal problems as administrative issues, but as an experienced health-care administrator who personally witnessed the internal operations, I can tell you with certainty the problems stemmed from clinical issues due to inadequate staffing of properly trained physicians and nurses and the personal in-fighting between Kaiser transplant surgeons and transplant nephrologists.Kaiser violated the covenant of public trust between patients and physicians. Thousands of real people endured unnecessary pain and others suffered unnecessary death. In health care, the unnecessary death of a patient is the strongest indicator of quality of care or in Kaiser’s case, lack of care. It doesn’t get any more clinical than that.David MerlinFormer director, Kaiser Kidney Transplant Program San Francisco

It’s worth saying again that the crux of this whole thing is not only was there a screw-up of huge proportions on the UNOS-Kaiser hand-off, but there is the strong suspicion–highlighted by what Merlin says and intensified by Halvorson boasting about the successful outcomes of the transplants that were done–that the KP surgeons were cherry-picking their cases and leaving the marginal ones on the waiting list (if indeed they ever got onto the "new" waiting list). If the meeting between the nephrologists and the senior Permanente staff Merlin talks about took place, you can bet that that was at least one topic of conversation.

Continue reading…

POLICY: Massachusetts Update By Eric Novack

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I must admit when I am wrong. My repeated claims that the Massachusetts Health Plan would
be on life support—with a likely ‘pulling of the plug’—by early 2008 have been
proven wrong.It has happened already.

 

POLICY/INTERNATIONAL: More boring pointless mush from the AEI

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So the WSJ gives another know-nothing big oil-sponsored hack from AEI another forum to use the same tired defense of the US system in the Elizabeth Edwards case. Oh look! Cancer outcomes are worse here than in Europe therefore their health care systems must be worse. With the unspoken implication that if her husband’s plans get enacted she’d be dead.

Just for a minute ignore all the other issues about costs, the 18,000 people whom the IOM says die each year here earlier than they would in those European countries because they’re uninsured, medical bankruptcies up the wazoo, etc, etc, and feast your eyes instead on this little nugget from a much longer article at the Annals of Internal Medicine.

Contrary to popular belief, the health care here isn’t always the best. Many other industrialized countries provide health care that is just as good and sometimes better. For instance, 30-day acute myocardial infarction case-fatality rates are below 7% in Denmark, Iceland, and Switzerland, compared with almost 15% in the United States. Incidence of major amputations among diabetic patients in Finland, Australia, and Canada is less than 10 per 10,000 compared with 56 per 10,000in the United States. And Australia, Canada, England, and New Zealand all have a better 5-year kidney transplantation survival rate than the United States.

There are so many better things to be arguing about.

But if the AEI and the fake free-marketeers want to play that game, why is the American health care system killing people with heart attacks, or chopping the legs off diabetics at more than double the rate of foreigners? Does the AEI really want to go down that path–particularly as there are way more Americans  with heart disease and diabetes than with cancer.

CONSUMERS: Interested in doing a book review?

Citiria Publishing is looking for a reviewer for a patient self-help book, "Heart Bypass – The Road Map".

Please contact clive ‘at’ citiria.com. If it’s good I’ll print the review here.

QUALITY: Plantar warts, duct tape and the real cure

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David Williams at Health Business Blog pokes some fun at some investigators looking into a cure for plantar warts who used the wrong type of duct tape in trying to figure out if this cure works. (He calls it File this in the “What were they thinking category?”).

However, having had one of those miserable bastards (a wart that generates it’s own dang blood supply) and failed to get rid of it in the conventional way (acid that  kills the rest of the skin on the foot but not the plantar wart) I know the answer. It’s this stuff. http://www.amoils.com/warts.html Works exactly as advertised. This is the only medical product I’ve ever endorsed, and no they’re not paying me and don’t know about this posting! (OK, so it’s an “n” of one, but these guys are still in business 4 years later….)

HEALTH PLANS/CONSUMERS/POLICY: Administrative costs–bad and will get worse with CDHPs

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PNC Bank has a new survey out saying that 30% of all health care costs are to do with administration—actually it may be more than that if you believe the study in Health Affairs that said it was 20-22% of all provider costs, when the public provider payer segment is keeping an additional 3–20% of all the dollars too. I think that PNC is trying to promote HSAs et al, and perhaps wants to suggest that this will solve the administration problem. As I’ve been saying for a while, the current set up of CHDPs just means that instead of chasing down health plans for the money, providers will be turned into consumer collection agencies.

And PNCs own survey shows that most providers agree with me:

Nearly three-quarters of hospital executives surveyed (72 percent) expect high deductible health plans, which require consumers to pay more upfront costs for care out of their own pockets, to add another layer of complexity to the claims, billing and payment process.

POLICY/HEALTH PLANS: Clowns to the left of us, jokers to the right…..

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Yet another study showing that even if you’re insured, because of the structure of our insurance system even the insured have trouble paying bills.  Now I know I should leave this well alone. It’s ground that I’ve trampled to death before, such as this story about the insured parents of the sick kid who’ve declared bankruptcy. But when the magic four letter acronym of certain industry trade group pops up (even without a certain lobbyist’s name mentioned) I just can’t help myself.

Along with deductibles and co-payments, The Access Project found other factors associated with medical debt were annual or lifetime "caps" on benefits; extra charges for "out of network" care, even when admitted to in-network hospitals; and complex billing systems by insurers and hospitals that left patients confused about what they owed.

Mohit Ghose, spokesman for the industry trade group, America’s Health Insurance Plans, says the study unfairly blames insurers for rising costs. He says there are many reasons spending on health is going up, including new treatments and drugs, rising demand as the population ages and "defensive medicine" by providers worried that they will be sued if they don’t run every test or offer every alternative to patients. "For too long, people have found it convenient to put any and all problems with the health sector at the doorstep of health insurance plans," says Ghose.

Not actually a direct lie this time, you’ll note. But excuse me again, but if it’s not to sort out that stuff—the over use, the defensive medicine, assess the correct use of technology—then what do AHIPs members do for their customers other than slap on 20% and send them the bill? Not much is the answer.

But I guess AHIP is doing its job. They’ve been getting idiot libertarians from no-name universities to write ridiculous op-eds about the value private insurers bring to the system and than has succeeded in getting them placed in that bastion of Marxism The New York freaking Times!! I’ll spare you the whole thing (although this post at Economist’s View  explains largely what a pile of crock Cowen writes. But this choice piece of outright idiocy has to make an appearance at THCB:

It is precisely because competing insurance companies spend money evaluating the appropriateness of claims that they are willing to pay for so many heart bypasses, extra tests, private hospital rooms and CT scans.

Given what Ghose says in the line above about how insurers aren’t able to do that stuff because it’s just too hard for them, someone at AHIP has clearly not been communicating well with their pet blogger, or at least Cowen has no idea what a health insurer does. Perhaps he should try to get a job at HBS? He’d fit in well there

And given that Cowen is an out-there libertarian nut with no basic chops in health care, and for whom this is his second recent appearance in the Times, it’s worth asking how many op-eds has the Times featured from Alain Enthoven, Vic Fuchs, or anyone else with half a brain on the topic this year? You know my guess as to the answer.

PHARMA: WSJ’s new blog, NCAA and The Industry Veteran‘s handicapping

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The WSJ has a new health blog. Should be good to keep tabs on—focusing mostly on the business of health care. No posts from Barbara Martinez as yet (pity!). One of their earliest posts is a comparison of March Madness basketball with Pharmabrackets. The Industry Veteran is amused but not too impressed:

The March Madness tournament in NCAA basketball has made millions of office workers with too much time on their hands look at the world through elimination brackets.  I don’t know if this is an improvement over their tendency over the past 20 years to conceive all existence in terms of spreadsheets.  What it has done is taken their parlor trick pastime into some unusual substantive areas.  The other day the Wall Street Journal published elimination brackets showing how they believe Big Pharma will devolve into a Final Four.  It’s amusing, but as with spreadsheets, regression analysis and other idiot-savant endeavors, it shows a thorough detachment from commonsensical reality.

PharmaBracketAny consummation of their elimination pairings runs afoul of some major impediments.1. GSK + AZ.  No way, Jose.  GSK’s biggest product is Advair and AZ is hoping Symbicort will be its second biggest.  A combination would have to axe one of the two.2.  Sanofi-Aventis + Novartis.  Not in this century.  S-A is France’s stake in the ground for a presence in Pharma while Daniel Vasella and his director allies at Novartis are devout Swiss nationalists.  More likely the US of A and France would merge to form one country.3.  Merck + S-P.  Makes sense in that Fred Hassan admits S-P needs pipeline and while S-P can bring marketing acumen to Merck, try getting the latter to admit they need that.4.  Pfizer + Amgen.  Amgen’s stock is down now because of their shenanigans on Aranesp, but as of 12/31 their market cap was just under $80 billion.  Pfizer didn’t do so well with its last megabuy when they acquired Pharmacia for around $60B.  I think Pfizer’s CEO Kindler and CFO Shedlarz would be out on their asses if they tried this.  Besides, Amgen chairman-CEO Kevin Sharer is the new president of Big Pharma’s lobbying group, PhRMA, and he wouldn’t sell his own company while he’s serving as the industry’s figurehead spokesman.

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