Category Archives: Culture

Cancer drugs: Why the high and rising prices?

Cancer drugs. Good stuff cheap?

Cancer drugs. Good stuff cheap?

When Americans talk, pharmaceutical companies listen. And what they’ve heard is that initiatives to contain or regulate medical costs get labeled as “rationing,” a word with very un-American connotations.

While politicians wring their hands, pricing strategists at pharma and biotech companies take action by charging high and rising prices for products for life-threatening illnesses. Cancer is Exhibit A, with many drugs costing more than $100,000 per year of treatment. A JAMA Oncology paper reviewed wholesale prices for cancer drugs approved over the past five years and found that prices are not correlated with a drug’s novelty or efficacy.

The authors conclude:

“Our results suggest that current pricing models are not rational but simply reflect what the market will bear.”

Now it’s possible that there is a greater correlation between actual negotiated prices and novelty or efficacy that isn’t showing up in the researchers’ data on wholesale prices. Still, the main conclusions are likely to stand, and spending on cancer drugs is sure to grow as more drug developers respond to market signals and develop new products.

If those who pay the bills, including private insurers, employers, and the government want to do something about cancer drug prices, they’ll need to embrace objective ways to measure cost effectiveness, and not be afraid of an opponent throwing around the “rationing” word. They’ll have to couple that approach with a commitment to personalized (or “precision”) medicine so that individuals get the specific drugs that are most effective for them, even if they don’t work as well for the general population.

The outcry over Sovaldi pricing for Hepatitis C has shown that there is at least some appetite to take on drug prices, but I don’t expect any dramatic clampdown on cancer drug prices in the near term.

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

Patient portals: Hiding in plain sight

Many physician offices have patient portals, since they’re a requirement for Meaningful Use Stage 2. But a new survey from Software Advice confirms what we knew intuitively – these portals don’t get much use. Patients don’t know they exist and doctors don’t use them a whole lot. That’s kind of odd considering that portals can be useful and efficient. They’re good for checking lab results, asking non-urgent clinical questions, renewing prescriptions, managing appointment schedules, patient education and paying bills.

Why then is uptake so low? I have a few ideas:

  • The systems are clunky -frustrating to navigate, often down for maintenance or for no explained reason, and slow
  • Workflows are awkward. For example a physician may have access but her admin may not
  • There’s often no value proposition for a physician who wants to use a portal
  • Messaging is inflexible with no access to attachments web links or other enhancements
  • Some of the more important communications, like sharing a diagnosis don’t lend themselves to asynchronous communications
  • Privacy and security remain concerns and the required safeguards create barriers

Contrast the weak state of portals, which have been available in one form or another for 20 years, with other changes in communication that have been embraced much faster. Think texting, Skype, and mobile commerce, all of which have rocketed to prominence since patient portals were invented. I do think we’ll get there, but it will take a new generation of doctors, patients, software developers and payment models to make it happen.

You can find the original item from Software Advice here.

Medicaid expansion rejection starts to bite

What happened to my hospital?

What happened to my hospital?

In its ruling upholding the Affordable Care Act, the Supreme Court did allow states to opt out of the expansion of the Medicaid program, which serves the poor. My feeling at the time –and still today– is that you’d have to be pretty ideologically rigid and stubborn or just plain uninformed to turn down the expansion. The feds pay 100 percent of the expansion’s cost in the first three years and at least 90 percent thereafter.

Try hard and you can find reasons to oppose the expansion — maybe the feds will go back on their word, maybe Medicaid will make people lazy– but these are hypothetical and farfetched. Meanwhile, the costs of not expanding Medicaid are very real, in the form of billions of dollars in foregone funding for the provision of healthcare to the poor and the undermining of communities that lose their hospitals.

Twenty-four states, including almost the whole South, took the stubborn path and have so far refused to expand Medicaid. They’re starting to experience the consequences.

A George Washington University study reveals that more than 1 million patients who use community health centers will lose out on coverage because their states refused to expand. One-third are in five Southern states: Alabama, Florida, Georgia, Louisiana and Mississippi.  That’s putting a strain on community health centers, many of which will lack the funding to provide needed care.

Meanwhile a Wall Street Journal article (Rural Hospitals Feel Pinch) highlights the strains confronting rural hospitals as the world changes around them. The article features a hospital in a rural North Carolina community that’s closing. In the 21st century, losing a hospital is a major blow for a town or rural region. It’s often the biggest employer, a major driver of other local businesses, and a key to quality of life. Once it’s gone it’s not coming back any time soon.

Failure to accept the Medicaid expansion isn’t the only reason rural hospitals are struggling, but it’s a big part of the equation. Southern politicians are trying to make policy changes to shore up rural hospitals, but their efforts are a drop in the bucket compared to the funds that flow from the feds.

Rural America is the most Republican part of the United States. At least on Medicaid expansion, many rural citizens are poorly represented by the people they vote for. There’s an election coming up in November and folks would be wise to re-examine their assumptions before casting their ballots.

photo credit: Range of Light via photopin cc

By healthcare consultant David E. Williams of the Health Business Group

It’s ok to care about your work, especially if your job’s at a children’s hospital

Who cares?

Who cares?

The Wall Street Journal has become more like Cosmo since Rupert Murdoch took it over, with all sorts of advice on life and work mixed in with the serious business and other news. Some of the articles are pretty decent and I enjoy reading them, even if they are a bit fluffy.

Sue Shellenberger’s piece (When It Comes to Work, Can You Care Too Much?) is about people who love their employer so much that they get carried away and take things too personally. They care about whether someone is wrongly promoted in another department and get upset when their employer strays from its mission.

We learn of the two types of people, the “organization lover” who cares too much but is a strong team player, and the “free agent” who is more calm but also seen as cynical.

The impetus for the article is a book by an employee who “fell in love” with BP because she heard the CEO talk about reducing greenhouse emissions. Eventually she became disillusioned and wrote a book about it. The article seemed like a harmless diversion about a pretty obvious topic. Clearly it doesn’t make sense to get too carried away about working for an oil company, you don’t want to be a busybody obsessed with everyone else’s business, and there’s a need to strike a balance.

They could have left it at that.

But then the very last example was about a nurse educator who moved from an internationally renowned pediatric hospital to a small hospital when her fiancee got transferred.

Employees there were using what she regarded as outdated methods of managing infants’ breathing tubes and other aspects of respiratory care, says Ms. Pender, who had worked as a neonatal intensive-care nurse for the Children’s Hospital of Philadelphia.

“I didn’t want to come across as a know-it-all,” she says. She quietly observed her colleagues. She met with a nurse educator and showed her research and videos on new techniques. She created a written survey for other nurses, asking their opinions. And she sought out allies, joining a hospital task force on improving care. Then a new manager arrived who supported her ideas.

Ms. Pender and her fiancé recently moved back to the Philadelphia area, and she rejoined Children’s Hospital. Her former colleagues have adopted many ideas she advocated. She says she’s happy to know “positive changes are moving forward.”

I honestly don’t think this last example is really about loving your employer too much. If you’re going to work in healthcare –especially taking care of infants with breathing tubes– you better care about patients and their families. It should have very little to do with whether you are the type who likes or loves your employer.

photo credit: Kalexanderson via photopin cc

By healthcare consultant David E. Williams of the Health Business Group

Patient failed his therapy or vice versa?

Who failed?

Who failed?

The other day I heard a physician use a phrase I really don’t like. “The patient failed his therapy,” he said. Although I don’t want to be too picky about wording, I find that formulation to be quite disempowering and depressing for the patient.

Imagine a sick patient who tries a promising drug with the hopes of improving or being cured. It’s bad enough when a drug doesn’t work, but if the patient is made to think he’s failed as well that doesn’t seem very constructive. It would be more accurate and less threatening to say that the therapy failed the patient.

Going a step further, it might also be accurate to say “the physician failed the patient,” but I don’t think doctors would want to think of it that way!

Misattribution of blame is not unique to the heallthcare industry. Another example is provided by airlines, who are eager to avoid being faulted when they screw up. In recent years I’ve started to hear airline employees say, “the flight has cancelled,” making it sound somehow like the plane itself decided not to fly. A more accurate statement would be, “the airline canceled the flight.” Now they may have had their reasons, like bad weather, but even the most modern planes don’t cancel their own flights.

But back to healthcare, I hope physicians and other healthcare professionals will be more conscious of how the language they use affects how patients feel about themselves. It doesn’t mean walking on egg shells; instead it means trying to be empathetic, and soliciting constructive feedback from other members of the care team and patients and families themselves.

I don’t mean to make too big a deal of this. In fact, most physicians don’t use this “failure” terminology these days and I’m glad they don’t.

 

photo credit: LifeSupercharger via photopin cc

By healthcare consultant David E. Williams of the Health Business Group

 

Give Boomer Esiason a break on birth comments

Retired football star and current radio host Boomer Esiason has opened the floodgates of righteous indignation by suggesting that the Mets second baseman should have encouraged his wife to have a scheduled C-section before opening day. That would have prevented him from missing the first two games of the season when he flew home to be with her.

Esiason got the blowback that he should have expected, and made a lengthy apology for his comments today.

I’m happy though, that this mis-step has turned into an opportunity to educate people about the dangers of early elective delivery. There’s actually been a major, successful effort underway to reduce the use of early elective deliveries. Such deliveries –either induced or scheduled C-sections before 39 weeks– represented 17 percent of births in 2010 (as high as 25 percent in some states). As of 2013 the rate has fallen dramatically, to less than five percent according to the New York Times.

It turns out babies born at 37 or 38 weeks have a lot more health problems then those born at 39 or 40  weeks, even though it doesn’t seem that such a short time difference should be so important. So I hope the reaction to Esiason helps to get this message across.

Esiason is getting the word out. Here’s what he said:

I’m very grateful to my many friends over at the March of Dimes who graciously reached out and re-educated me that if a pregnancy is healthy, it is medically beneficial to let the labor begin on its own rather than to schedule a C-section for convenience. In fact, babies born just a few weeks early have double the risk of death compared to babies born after 39 full weeks of pregnancy. As their promotional campaign says, ‘Healthy babies are worth the wait.’ And as a proud father, I couldn’t agree more.

I find it quite interesting how societal expectations about fatherhood have changed in the recent past. A generation ago, the notion of a father being in the delivery room was unheard of. Fifteen years ago I had a job interview with a large financial services company. The hiring manager (in his early 30s at the time) told me the job required an all out commitment, and that while he hoped to be present at the birth of his child, that wasn’t really the way things were prioritized there. I didn’t agree with that sentiment then, but it was the norm in many places.

So it’s interesting to me that Esiason took it for granted that the player would be present for the birth –he didn’t seem to question whether work should come first.

Esiason said the wrong thing, but I think we should cut him some slack. First of all, being a football quarterback is different from being a baseball second baseman. Baseball teams play 162 games per season, NFL teams only 16. A star quarterback plays every game, whereas even star baseball players get a day off from time to time. So maybe we can accuse Esiason of lack of empathy for thinking about how he would have behaved, not what a baseball player would do. But I understand his point about not wanting to miss a game.

Esiason is 52 and times have changed. He gets part of the new way of thinking –dad should be there for the birth. But he screwed up by suggesting unnecessary surgery. And while I don’t fault him for not knowing that earlier births aren’t good for babies, at least it gives people a chance to bring it up and make it known to a wider audience of would-be fathers who might otherwise not be paying attention.

By healthcare consultant David E. Williams of the Health Business Group

 

CVS and cigarettes: Asking the wrong follow-up question

After CVS, what's next for smoking?

After CVS, what’s next for smoking?

CVS’s decision to stop selling cigarettes is a smart one. Cigarette sales are incompatible with the company’s positioning as a health care provider. With the reduction of smoking rates, growing restrictions on where people can smoke, and increasing numbers of localities banning cigarette sales in drug stores it will probably make business sense over time as well.

I’ve been surprised that so much of the commentary on CVS’s decision has focused on what else the company should stop selling. Candy, gum and soda are bad for you, too, so maybe CVS should stop selling that. And the list goes on from there –maybe some of their toys are dangerous, for example.

Asking what else CVS should stop selling is asking the wrong question. Cigarettes cause an order of magnitude more harm than those other categories and are more addictive. That’s a good reason  to stop selling smokes without having to stop selling other things that aren’t 100 percent healthy.

I’d like to see a bigger emphasis on reducing the availability of cigarettes more broadly and making them more expensive.

Cigarette taxes vary wildly by state. Missouri is the lowest at $0.17 per pack and New York is the highest at $4.35. (New York City tacks on an additional $1.50.) The federal tax is $1.01 and some places add other taxes including state and local sales tax. The average retail price for cigarettes is about $6, so tax represents a big part of the price.

These big differences provide a major incentive for smuggling. Although no one knows exactly what percentage of cigarettes are smuggled, it’s a lot.

Indian reservations are another source of low-tax cigarettes. High tax states like New York have seen considerable friction as non-Indians have sought out on-reservation stores for bargain prices.

The effects can be insidious. A friend told me recently about a public housing project in his area where a man goes door to door selling cigarettes he obtains cheaply on a nearby reservation. If the price were higher the rate of smoking in this price sensitive population would be likely to decline.

I’m not proposing a specific mechanism to address these challenges, but I would like to see the low tax states raise their tax rates,  more enforcement effort devoted to stopping interstate smuggling, and more aggressive action to reduce the availability of reservation cigarettes. Although this will never happen, one approach could be fore the federal government to charge a tax of $6 minus whatever the states charge. That would provide an incentive for every state to raise the tax to a uniform, high amount.

photo credit: The Guncle via photopin cc

By David E. Williams of the Health Business Group.