EpiPen may still be too cheap

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Good stuff, cheap

Pick up a newspaper or surf the web and you’ll find story after story taking Mylan to task for EpiPen pricing practices. The list price of a 2-pack has soared from about $100 to $600 over the past decade. The price is deemed too high and the rate of increase is considered particularly unconscionable.

Let me offer a brief counterargument:

  • EpiPen is worth the price. A $300 pen regularly rescues children from anaphylactic shock that would otherwise be fatal, offering them the chance to live to 100 instead of dying at 10. (About 20% of patients need a second dose, which is why these devices are sold in 2-packs.) Meanwhile drug makers charge hundreds of thousands of dollars per year per hemophiliac, tens of thousands or more to give a cancer patient a shot at a couple or few more months of life, and thousands per year to modestly lower the chance of a heart attack. Within that context, and in absolute terms, EpiPen is indeed a bargain.
  • People are complaining that they pay hundreds of dollars per year –or more if they have multiple packs– for something they hope never to use. But they should acknowledge that they are actually using EpiPen even when they never dispense the drug. EpiPen is what lets them send their children on playdates and be comfortable with them away at school and summer camp, go out to restaurants, and take hikes in the woods.
  • EpiPen is worth a lot more than its current and former competitors. According to the Washington Post, Twinject left the market in 2012 and was considered clumsy and unappealing compared to EpiPen. Auvi-Q was recalled last year because it could administer the wrong dose. Teva’s autoinjector was rejected by FDA this year for “major deficiencies.” How many parents would be willing to trade down to save a few dollars on these? Anybody?
  • The failure of Adrenaclick to catch on despite a lower price, distribution through Walmart and a good review from Consumer Reports demonstrates that Mylan has done a lot with EpiPen over the past decade to earn its price premium and high market share. In particular, EpiPens are now close to ubiquitous in schools thanks to clever marketing, effective lobbying, and public health campaigns. School nurses know how to use them, babysitters know how, and so do siblings. When an emergency strikes and seconds count, the familiar tools are at hand, and people are ready to act. It doesn’t really feel like the moment to learn about Adrenaclick for the first time!
  • In effect, Mylan has created a public health support system around EpiPen. I’ll go ahead and make myself even more unpopular by saying that this system justifies the big price increases. When you buy EpiPen in 2016 you’re not just getting the product like you were in 2007, you’re benefiting from the whole system. Although the product itself hasn’t changed, EpiPen is more valuable now than it used to be, and Mylan has justifiably reaped the rewards.

EpiPen is far from perfect. For example, it needs to be stored within a tight temperature range and protected from light.  The pens have to be replaced annually. Other companies are working on EpiPen alternatives, and I’d like them to have a financial incentive to do so. A cheaper EpiPen could be nice, but I’d rather see something that’s better (easier to use, more effective, more stable), even if the price is higher. The current attacks on EpiPen are unfortunate because they discourage investment in these types of innovation.

Before you dismiss these arguments and call me an industry hack, I’ll point out that I have advocated for drug price regulation since 2006. But EpiPen is not the place for the government to intervene.

Image courtesy of Sira Anamwong at FreeDigitalPhotos.net

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

Surprise, surprise! Exchange customers are price sensitive

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Uh oh. Another big national health plan, Aetna has decided to pull back from the individual health insurance marketplaces (aka exchanges) deciding they can’t make money because customers are focusing on price, not brand name. The headlines give a sense of it:

Cost, Not Choice, Is Top Concern of Health Insurance CustomersNew York Times

Customers’ Laser-Like Focus on Plan Prices Is Causing Concerns in Health Insurance MarketKaiser Health News

The articles quote insurance executive and experts claiming that “price competition has turned out to be much more cutthroat than anyone expected” and that “people signing up for [broad network, big employer style coverage offered by the big name national health plans] are less healthy –and more expensive to treat– than anticipated.”

Hah!

As I have written before (Good riddance: United finally gives up on ACA marketplaces):

Health plans thinking of competing in the marketplaces should say this to themselves a few times before diving in: “Exchange business is price sensitive business. If we can’t compete on price we might as well stay home.”

The exchanges do have problems. For example, insurers are limited to charging older people 3x what they charge younger ones, whereas actuarially it should be more like 5x. The problems are eminently fixable, except that opponents of the law still want it to fail. As for Aetna, specifically, it seems they are retaliating against the feds after the government announced its opposition to Aetna’s merger plans.

Nonetheless, why would we measure the success of the exchanges by whether the big, fat brand name health insurers can make money? Exchanges allow customers to compare plans on an apples-to-apples basis and they are deciding that there’s no big reason to pay higher prices. Some health plans are thriving on the exchanges by negotiating hard with providers (Medicaid oriented plans like Centene and Molina) or by having local market knowledge and density (Blue Cross Blue Shield of Florida  –which has almost as many Obamacare customers in Florida as Aetna has in the whole country).

Here’s the real problem for health plans: they have largely failed to demonstrate that they add significant value. Aetna, United and their ilk don’t accomplish a lot compared with Joe’s health plan. And even when they do add value, they still add large administrative costs and inefficiencies to the system that may outweigh their benefits.

The Affordable Care Act has actually given health plans a new lease on life, by herding in new groups of individual customers and by imposing whole new sets of standards and rules. Health plans fear a so-called “public option” because it could reveal that commercial plans don’t bring much. And as unlikely as it seems now, it’s quite possible that the failure of commercial plans to demonstrate value could lead us eventually to a single-payer system.

Ideally, I’d rather not see single payer. If some of the plans were a little more ingenious and capable they could actually prosper in the exchange business, in ways that would boost their success in the commercial market as well. In particular, there are opportunities to better manage the way specialty care is delivered and paid for, by emulating the approaches used by the most efficient and innovative specialists. This would drive down the overall cost of insurance and improve care for patients.

Plans could also be more creative and resourceful in helping providers take risk or even full capitation.

Meanwhile, Aetna will struggle to grow. After all, the US is moving toward marketplaces and government coverage. Aetna, not Obamacare or the exchanges, may turn out to be the big loser here.

Image courtesy of Stuart Miles at FreeDigitalPhotos.net

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

 

Health Wonk Review is up at Healthcare Economist

Healthcare Economist hosts the Short and Sweet Edition of the Health Wonk Review blog carnival. Here you’ll find posts on health insurance, mental health, pharmaceuticals, physician pay and value measurement.

I’ll be hosting the next edition at the Health Business Blog. Have a post to submit? Use the contact link at Health Business Group to send it my way.

Medicare and the end of racial segregation in healthcare

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The story of how Medicare ended segregation in healthcare settings is a pretty remarkable one. Temple University Professor David Barton Smith’s  The Power to Health: Civil Rights, Medicare, and the Struggle to Transform America’s Health Care System brings the events of 50 years ago to light.

“In four months [government bureaucrats] transformed the nation’s hospitals from our most racially and economically segregated institutions to our most integrated,”he writes. “A profound transformation, now taken for granted, happened almost overnight.”

In the early 1960s healthcare was even more segregated than the economy as a whole. In Southern states there were separate hospitals for whites and blacks; there were separate waiting rooms in physician offices, with black patients seen last.

The 1964 Civil Rights Act prohibited racial discrimination in programs that received federal funds. But when Medicare was enacted in 1965, no one really took the provision seriously. After all, the Brown v. Board of Education decision a decade earlier had not led to rapid progress in school desegregation.

And yet Wilbur Cohen and a small team from the Social Security Administration and Public Health Service put together rules that prevented hospitals that discriminated from receiving Medicare funding. Learning their lesson from the failure of Brown’s “all deliberate speed” language, which had let school segregation fester, the team decided to enforce the rules from day 1.

Since hospitals couldn’t afford to forego Medicare, desegregation was achieved in a matter of months. Imagine that.

Image courtesy of podpad at FreeDigitalPhotos.net

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

MGH marketers take on Boston Children’s

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The doctor will see you now –and forever

I was driving along in Boston last weekend when I heard an intriguing radio advertisement for MassGeneral Hospital for Children, the pediatric division of Massachusetts General Hospital (MGH).

MGH is a world famous hospital, but when it comes to pediatrics it’s much smaller, less well known, and lower ranked than Boston Children’s Hospital –the #1 rated children’s hospital by US News.

I thought MGH picked a clever angle for the ad: highlighting a patient with Crohn’s disease who was diagnosed at age 10 and is now an adult. The message: illnesses that occur in childhood may need ongoing care into adulthood. Therefore why not start with a hospital that cares for children and adults? Boston Children’s isn’t mentioned, but it’s the clear target.

The Crohn’s example is not accidental. It’s a fast growing illness among kids, and it lasts for life. I don’t have the data but my sense is that it must be a highly profitable line of business for hospitals because of the frequent surgeries, endoscopy, and use of biologic drugs. (I would have been surprised if they had uses a common but non-lucrative disease like diabetes.)

The transition from a pediatric to adult gastroenterologist is an important step on the patient journey. A bad transition can be stressful and even lead to worse health outcomes. I’d be interested to learn what processes MGH has in place to make the transition smoother for its patients than what Children’s can offer. (I’ll have to research that.) It’s also unclear how highly to weigh this factor when choosing a place for a child to be treated, especially if that child might move away for and after college.

I don’t want to sound too cynical on this. In my own experience, I’ve seen physicians from Children’s and MGH –including in gastroenterology– collaborate closely to help one another’s patients. If you have a child with inflammatory bowel disease and live near Boston, count your blessings.

Image courtesy of kdshutterman at FreeDigitalPhotos.net

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

Smoking and the ACA

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The Affordable Care Act (ACA) has created a wonderful laboratory for studying the impact of changes in healthcare policy. One of the more interesting papers on the topic appears in the latest Health Affairs (Evidence suggests that the ACA’s tobacco surcharges reduce insurance take-up and did not increase smoking cessation). (You’ll need a subscription to read the full article.)

Health plans can’t charge higher prices to people who are sicker, but they can tack on surcharges of up to 50 percent for tobacco users. States can limit or ban the surcharges, and some do. Not surprisingly, people subjected to high surcharges are a lot less likely to purchase insurance, especially because the way the surcharges work has a very significant impact on their out of pocket costs.

Beyond the headlines, there were several additional findings:

  • When smokers faced no, moderate or high surcharges rates of smoking cessation were unaffected
  • Low surcharges significantly reduced the degree of smoking cessation
  • Young smokers were much more likely than older smokers to be deterred from health insurance coverage by the imposition of surcharges
  • Surcharges were typically higher than the extra medical costs incurred by smokers

These findings have some interesting implications:

  • If the goal of the surcharge policy is to get people to quit smoking, then it doesn’t seem to be working very well. The least effective approach of all is to impose low surcharges. The authors speculate that the low surcharge smokers may feel they are being fairly charged and therefore don’t have an incentive to change. This is like the parents who are more likely to pick up their kids late from day care when a small fine is imposed
  • Surcharges knock younger people out of coverage disproportionately, which may destabilize the risk pools since younger people are generally more profitable than older people
  • The rising penalties for not purchasing insurance may not have much effect on smokers who face surcharges. Many low or moderate income smokers will be exempt from the penalties because the premiums –with surcharges– are deemed unaffordable
  • Patients with mental health problems are being discriminated against because they have much higher smoking rates than the general population. (I have been making similar arguments since 2007)

The authors mention in passing that high surcharges may encourage people to quit in order to obtain affordable coverage. They also note that the smoking surcharge isn’t always apparent on the exchanges, so smokers may not understand that they are paying more or how much.

I’d like to see the law tweaked to make the financial consequences of smoking more apparent to smokers. Surcharges could be displayed more explicitly, and the bar for being exempt from the insurance coverage requirement could be raised. Exceptions could be made for those with a mental health diagnosis.

These changes won’t necessarily be easy to achieve. Congress so far shows no signs of being willing to improve the law –though that may change if the Democrats retake Congress. Another issue is that tobacco use is generally self-reported for exchange customers, so we don’t know how many people are classifying themselves as non-users when in fact they are not.

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