When Prescription Information Looks Like A Rubiks Cube...

A lot of what I've talked about on this blog so far centers around small improvements that can be made to the U.S. healthcare system. Small improvements like checklists for surgeons and less administrative costs could lower spending more than you could imagine. I want to bring up another small improvement: focusing on health literacy and making sure patients understand the medications they are putting into their body.

Each year, millions are spent treating patients in the ER who misunderstand their medication. Who is to blame? The Wall Street Journal Health Blog posted recently about the FDA stepping in on this issue. They propose making the information that comes with medication more efficient. Instead of medication coming with multiple pages of information and additional promotional material from drug companies, it would come with a simple one- sided sheet with only the most important information. The bottom of the sheet would direct patients to a website for more information.

Some have harshly criticized this idea. Saying that 1 page is not enough to cover all important medical instructions. Others have said 1 page is enough to cover a bullet-ed list of essential medication instructions.

My opinion is two part:

1) The amount of information that comes with medications now is out of control. I recently picked up a prescription and had no idea where to start. Pages of information, promotional material, stickers. 1 page is definitely enough. Show me the dosing information, how to take the medication, and a number I can call if I don't understand something.

2) It doesn't end with simplifying the information. If you want to reduce medication misunderstandings, communication between patients, doctors and pharmacists MUST be stressed more. Patients should feel comfortable enough to ask when they don't understand. Doctors and Pharmacists should be willing and able to communicate with their patients.

Doing so will save a ton of time and money. I'm curious if anyone else has had a similar experience? Are you often confused by a medication you receive? If so, how can this be improved? Can essential information fit on one page?

Fixing Medicare

When ideas of healthcare reform began the question being asked was: Should we fix Medicare? With debates about the federal deficit swirling, the question has now become: How should we fix Medicare? The shift in positions and increase in urgency has come from the acknowledgement that Medicare is broken, and its costing the U.S. a ton of money.

It's easy to say we should fix Medicare; Actually figuring out how is a tad more difficult. As outlined in this New York Times article, President Obama's deficit reduction committee has considered a number of options. These options include (but are not limited to) :

1) Increasing the eligibility age for Medicare from 65 to 67
2) Requiring beneficiaries to pay higher premiums
3) Charging Co-payments for home health services
4) Paying doctors in "lump" amounts for entire treatments as opposed to paying for each step (tests, procedures) individually

The list goes on. For the complete range of options, check out the article. It's hard to say which option is best because all have pros and cons. For example, raising the eligibility age would save the government money for those two years, but those 65 and 66 year old patients might now be eligible for Medicaid. This just displaces the cost from Medicare to Medicaid.

Whichever solution is chosen, it will have to be supplemented with one thing: more efficient care. Changing the structure of Medicare will do nothing if health care is still administered in an inefficient way. This means, reducing medical errors, hospital infections, and administrative costs. More efficient care means cheaper care in the long run.

Fixing Medicare will probably require a pretty creative solution. What do you think is the best way to tackle this problem? Do you agree that any change needs to be supplemented with better health care? Will raising premiums do anything?

Optimism in Medicine

Although this blog generally centers around health economics and policy, an article I read in the New York Times made me want to switch it up today. Let's talk about ethics and optimism. Specifically the ethics of early stage clinical trials and patient optimism.

The article I linked to above, starts with a touching story about a mother in her 30's with cancer. If you have a few minutes, the article is a must read. Aside from being a story about selflessness and courage, it also raises a tough ethical debate about optimism and patient consent.

The woman in the story had been through numerous, experimental clinical trials. The purpose of these early stage clinical trials is often to test the safety of a new drug and not to actually treat the patient. In the story, doctors told the woman exactly that: she shouldn't expect this to benefit her, it was just for the purpose of advancing science. Although the woman confirmed that she knew this...I can't help but wonder if she had at least some hope and optimism about the experimental drug.

I truly believe that optimism is a gift. However, some are debating if unrealistic optimism is an ethical issue in this case. Studies in the article show that patients can be filled with optimism in clinical trials even when only 5 percent of patients see "some" benefit from these trials. Some argue patients are going into these trials without knowing the true purpose them and unrealistically expecting to be cured. When this is not explained clearly enough to patients, it presents an ethical dilemma.

Is there such thing as unrealistic optimism? Do you think having unrealistic expectations is harmful to patients?

Personally, I believe that any kind of optimism can only help in this situation. However, I do believe that every single patient is owed a clear explanation before they enter an early stage clinical trial. Patients need to know that the purpose of the studies they are participating in. They have the right to know early stage clinical trials are strictly about efficacy. If after knowing all of this, a patient still wants to be optimistic, that is an admirable decision that should solely be reached by them.
Your opinion may differ though. Some believe that by realistically explaining this to a patient you are ruining hope and harming the patient. Looking forward to seeing all sides and opinions.

Drug Shortages Becoming a Crisis

According to The Wall Street Journal, U.S. hospitals are facing a drug shortage crisis. This shortage could be causing breaches in medicinal safety and an increase in hospital costs of over 200 million dollars annually. The alarming part of this problem is that it applies to important chemotherapy and emergency treatment drugs. The shortage is requiring doctors and pharmacists to seek treatments that ultimately do not match the effects of the original treatment or cost more.

For example a brand name drug called Fusilev is being used to fill the shortages of a generic version called leucovorin. While the generic that is in short supply costs $7.41 a dose while the branded drug costs $177 per dose.




The problem has become so dire, that in some cases the FDA is allowing non-FDA approved drugs from overseas to act as replacements.


Who ultimately has responsibility for this? Do you believe generic drug makers have the responsibility of investing capital to build resources that can handle the volume of drug demand? What incentives could be provided to increase production of these drugs? Should the FDA be allowing use of unapproved drugs from overseas? What will be the solution to this issue ultimately?

Waivers and Weakness

An earlier post detailed the recent step backwards President Obama took by allowing states to apply for waivers to the Affordable Care Act. These waivers would allow states to drop the mandate for individual  health insurance as long as an effective, affordable alternative was reached.

Since the last post, there have been a number of reactions to President Obama's decision. A recent NY Times Article shows that along with Maine, five other states have applied for these waivers including Florida, Georgia, Kentucky, Nevada and New Hampshire.

Instead of praising President Obama for his decision, many Republicans are labeling it as a sign of weakness in the law. They argue that if the law was a good law, it would need no waivers. Many see the law as pointless if there will be so many waivers allowed.

Is providing waivers an admission that health care reform is weak? Is this proof that the Affordable Care Act is not perfect?

The Future of Patient Care....Not Just Yet

Ideas about health care are continuously evolving. One vision shared by many, is a medical future characterized by team-based patient care. As explained by this piece in the NY Times, this vision would involve converting traditional medical centers to "patient centered medical homes," where patients are seen by a team of doctors rather than just one individual. This team of doctors would also focus on cost cutting measures like preventative care. The overall goal of this vision is to create efficient, high quality care at an affordable price.

Sounds nice right? Unfortunately this dream is not yet a reality. 36 small practices tried to make this conversion and have run into a number of issues. The primary issue being the time and difficulty of converting traditional medical centers into patient centered medical homes. Eventually, I believe this will become a reality for the U.S. health care system. It just needs more time.

After reading the article and my post, what issues do you see arising with team  based care? It sounds nice on paper... but will it work in a real setting?

Is the Age of the Blockbuster Over?

For pharmaceutical companies, the 90's and early 2000's were the age of the blockbuster drug. Pharmaceutical companies developed drugs that could be used by huge patient populations and could rake in revenue from their respective drug patents. According to the New York Times, it is no secret that these patents are beginning to expire; but what is alarming for the industry is that there isn't much in the pipeline to replace them.

As patents begin to expire, major pharmaceutical companies will see significant erosion to their revenues from competition of generic brands. Add to this problem the lack of new drug discoveries, pressure from the government to lower drug prices and a series of heavy fines against pharmaceutical companies. This perfect storm of factors spells trouble for the pharmaceutical industry.

Why do you think drug innovation has slowed? Should the government still be  putting pressure on industry giants to lower their prices? Does pressure on price discourage innovation?

What strategy would work best moving forward? : focusing on branded generics, acquiring companies with near market ready drugs or concentrating only on health areas of need?

Obviously this article has a number of business, health and policy implications. It would be great to explore all of the different angles so feel free to comment.

A Solution to Ignorance about the Affordable Care Act

One of my earlier posts titled Ignorance & Healthcare presented research from the Kaiser Family Foundation about America's knowledge about the health care reform. A new website was launched this week that intends to better educate Americans on the Affordable Care Act (health care reform). The site is www.healthcareandyou.org and it was developed by a coalition of health care advocacy groups including the American Medical Association and the American Nurses Association.

The great thing about the site is its simplicity. Gone is the political debate that often clouds the facts of the Affordable Care Act. The site delivers the facts about the law tailored to each individual person. Users are greeted by a simple map of the United States and a clean home page. Once a user selects their state, they are directed to a page that contains everything citizens in that state need to know about health care reform. Further, this page gives users the option to classify themselves as "Under 65," "Over 65," or as an "Owner of a Small Business." The site then provides tailored information based on which role you choose. No advertisements, No Political Messages....Just the facts.

A site like this should have been established the moment the Affordable Care Act became relevant; but better late than never. What do you think about the ease of this educational website? Do you think it will be effective in helping American's understand this important legislation? Please feel free to share any comments you have.

Giving in On Health Care Reform?

On Monday President Obama took a significant step back on his health care reform bill. President Obama said that he is willing to amend the law to allow individual states to  opt out of the most critical aspect of the law: the insurance mandate. Under this amendment, states would have the option of not mandating health insurance for all citizens, as long as it could create some other viable option for coverage. In order to be approved for this waiver, the state must meet two requirements:

  1) The state must create another plan that will cover as many citizens as the original health care bill would.
  2) This alternative plan cannot further increase the federal deficit.

If this amendment is passed, states that earn a waiver will still be given the same money by the government to support their new plan.

Although the original law allowed for waivers to be applied for in 2017, Obama's offer to move this date up to 2014 is a significant step back for health care reform. The most important aspect of the bill is being diluted.

Should states be allowed to opt out of this insurance mandate or was the original health care law the best idea? Is this a political move to curb skepticism of the health care reform bill?

The Tradeoff: Medical Technology v. Personalized Care

In my last post I mentioned medical technology as a fiercely growing area that contributes to overall health care spending. In this post I wanted to look at the pros and cons of evolving medical technology (specifically electronic medical records). On one hand, this technology can make doctors extremely efficient, allow them to share patient data and save money by moving away from paper records; On the other hand the technology itself is expensive to implement, difficult to learn and can take away the "personal" feeling most doctors have with patients.

I have two articles that serve as a good contrast and explore this issue thoroughly. The first is an op-ed piece by Doctor Abraham Verghese about his personal experience with advancing medical technology. Doctor Verghese admits that on occasions he gets so caught up in technology, that it seems there is a "digital patient" and a real patient. He explains that advancing technology is starting to take away from the personal aspect of medicine. The second article is a piece by Steve Lohr about the pros and cons of implementing electronic medical records. 

Both articles, although written differently, give a great picture of the trade offs that come with medical technology. As a patient, which kind of medical experience would you prefer? A highly computerized visit that relies on technology for a diagnosis or a more personal visit that relies on doctor-patient interaction and intuition?

Healthcare Spending & End of Life Care

In August, 60 Minutes did a segment on end of life care and how much it costs the U.S. health care system each year. Although the video is from August, the issue it covers is still relevant today. This is a huge issue that comes with a gigantic moral debate attached to it.



The segment presents some staggering stats:

• U.S. spends 55 billion dollars a year  on hospital bills in the last 2 months of patients lives. This 55 billion  trumps both the annual budget for The Department of Homeland Security and The Department of Education. It is estimated that 20-30 percent of these procedures have no meaningful impact on the patient.
• One day in an Intensive Care Unit (ICU) costs over 10,000 dollars. 18-20 percent of Americans spend their last days in an ICU
• While a majority of Americans prefer to die at home, 75 percent die in hospitals & nursing homes.
• The government or private insurance pays for 85 percent of these medical costs

What are the underlying issues?

1. Medical technology has become so good that if patients want to, they can be kept alive much longer with advanced procedures and machines. The problem is, this is very expensive.
2. The U.S. health care system is built so that supply drives demand. This means that doctors are in control of the kind of medical care you demand because they suggest it. If the doctor suggests a certain treatment chances are you will demand that treatment. Doctors get paid by the patients they see and the tests & procedures they do so their incentive is to provide as much care as possible. This is also expensive.
3. Patients often never even see the medical bills they rack up because the government & insurance pays them. If they aren't paying nobody really cares how much these procedures cost.

It was amazing to hear the word "bankruptcy" brought up several times throughout the video. But that's how big of an issue this is; it can eventually bankrupt the United States. The problem is the huge moral debate. We can't just stop caring for people when they begin to die but at the same time a huge amount of money is being spent on this. Is there a moral middle ground or a way around this issue? Should end of life care be rationed or capped at a certain amount? It's a really hard debate to have.

Lower Healthcare Spending with...A Checklist?

Health care spending is out of control for a number of reasons: the health insurance system, U.S. lifestyle, lack of preventive care, prescription drug costs, administrative costs etc. A cure-all solution for health care spending is near impossible. Atul Gawande has a solution that can make a difference and it doesn't involve a controversial bill or fancy new medial technology. It's as common as something you and I use every day: A Checklist.



In the video above, Atul Gawande, a surgeon at Bringham & Women's Hospital, explains his idea for a 19 point hospital checklist. His checklist is something surgeons, doctors and nurses can use to prevent mistakes, infections and deaths during hospital stays. His checklist was initially tested in 8 hospital worldwide. In these 8 hospitals there was a 1/3 reduction in infections and deaths during surgery. A hospital in Michigan implemented the checklist and saw a 2/3 reduction of infections, saved 1,500 lives and over 200 million dollars.

This checklist is being used in less than 1/4 of U.S. hospitals. Imagine if this was required by all hospitals? Hospital infections are negative externalities that cost the health care system a ton of money. A low cost solution like Atul's could save a lot of lives and money.

Are there other simple fixes like Atul Gawande's checklist that can contribute to lower health care spending? Can an idea as simple as a checklist really save lives and money?

Another Point for Healthcare Reform

The New York Times reported on Tuesday that Judge Gladys Kessler of the Federal District Court for the District of Columbia became the 3rd federal judge to  uphold the health care reform bill. As detailed in one of my earlier posts the health care bill is currently working its way through a series of appeals in the U.S. court system.

Judge Kessler's decision on Tuesday makes the "score" of these appeals 3-2 in favor of upholding the health care reform. The most controversial part of the bill is the provision that would require American's to purchase some form of health insurance by 2014. The two judges that have ruled against the bill cited that this provision forces citizens to participate in commerce. In other words, it's causing them to "act" when they don't necessarily want to act. However, Judge Kessler determined that deciding not to purchase something as important as health care is an "act" on it's own.

Is a law too powerful if it is requiring America to purchase health insurance? Do you think this bill will ultimately be ruled unconstitutional if it rises to the Supreme Court?

FDA User Fees For Generic Drugs: Show us the Money

Dr. Margaret Hamburg, commissioner of the F.D.A., asked for new legislation on Friday that would require makers of generic drugs to pay the F.D.A. a "user fee." Each generic drug company would pay the F.D.A. a fee to expedite their approval process.

This is not necessarily a new idea; major pharmaceutical companies pay fees each year to speed up the approval process of their major drugs. Dr. Hamburg justified her call to action by explaining that the F.D.A. has many inspections and approvals to make and that user fees would allow the FDA to better serve the public.

Some criticize this idea because they feel it creates a conflict of interest between generic companies and the government.

Do you think the process of "user fees" is unfair? Does it promote a conflict of interest?

Sanofi Acquisition of Genzyme

Earlier this month French pharmaceutical giant Sanofi Aventis acquired locally based Genzyme Corp. This article from The Wall Street Journal has all the details of the major biotech acquisition.

Acquisitions happen all of the time in pharmaceuticals and biotech. Why is Sanofi's acquisition of Genzyme worth talking more about?

1) It positions an otherwise French based company in the east coast hub of biotech in the U.S. : Cambridge. This greatly improves Sanofi's position as they will have their hand on the pulse of the U.S. biotech industry. They will be more able to communicate and collaborate with U.S. based researchers.

2) The acquisition gives Sanofi a biotech arm. Genzyme specializes in biological drugs and enzymes that treat very rare diseases like Gaucher's Disease and Fabry Disease. Sanofi now has a position in the orphan drug market (drugs with very low patient populations).

3) Genzyme will keep its name and identity as a producer of orphan drugs. It will operate as a separate unit of Sanofi and will retain all current employees.

This acquisition was a major deal and one that has been looming for several months. Sanofi looks to be positioning itself to compete with other major U.S. drug companies. Looking at the terms of the deal and the benefits: Do you think Sanofi made a wise choice in acquiring Genzyme?

Insurance on the open market? Good Luck.

The New York Times recently posted an op-ed article about the difficulty of purchasing health insurance in the individual market. If you have the time to read the whole story, I highly recommend it. It shows just how hard it is to purchase health insurance if you aren't receiving it from your employer. The family in the story is not poor, unemployed or in bad health. Yet the U.S. health insurance system is so twisted, that this family was denied coverage several times before finally attaining it.

Although frightening, the story shows what life is like for those who do not obtain employee based health insurance. This family had the means to fully pay for insurance and still could not get accepted. Imagine what life is like for those in poorer health who cannot afford insurance.

Some major issues this story raises:
1) U.S. reliance on employee sponsored health insurance
2) The difficulty of getting health insurance with "pre-existing conditions"

Is the U.S. relying too much on employee based insurance? Is it fair for people to be denied individual health insurance based on minor procedures and ailments? Should congress really be working to repeal the health care reform bill that protects against all of this? It really is a tough call...so let's get a discussion going. 

Ignorance and Healthcare

The Affordable Care Act (health care reform) has generated an overwhelming amount of controversy. Political insults have been traded all amidst rumors of socialism and "government death panels."

Everyone is a critic. But when we open our mouths to talk about health care reform do we know what we are talking about? It would appear that an alarming amount of people don't. A professor recently passed a report along to me from the Kaiser Family Foundation on America's knowledge of the health care reform bill. The report surveyed a nationally representative sample of 1,207 adults and asked them questions about the elements of the Affordable Care Act. Below I've attached a chart with the results of this study.

Notice the percentage of wrong answers to questions on some very important elements of the act. A staggering 40 percent of people surveyed actually believe the U.S. government has the ability to make end of life decisions for patients. 65 percent wrongfully believe that all U.S. businesses will be required to provide health care insurance to employees. These aren't numbers that can be brushed aside. The Affordable Care Act is one of the most significant pieces of legislation passed in years, and a good portion of the citizens it applies to have no idea what it says. 

 I am of the belief that everyone is entitled to an opinion, as long as its a rational one. Some good questions: Why do you think there is such a disconnect here? Whose job is it to educate the American public on such important legislation? Let's hear it.

Health Care Act in Danger

On Monday January 31, the Affordable Care Act which many know as "the health care reform bill" was ruled unconstitutional for the second time since appeals began.

The controversial bill has now been upheld twice and ruled unconstitutional twice by appeal courts in Virginia, Florida and Michigan. This article by The New York Times explains that Judge Roger Vinson of The Federal District Court in Pensacola Florida labeled the bill unconstitutional on the grounds that it gives congress too much authority over commerce. The Affordable Care Act mandates that Americans must purchase commercial health insurance by 2014 or face penalties. Judge Vinson ruled that it is unconstitutional to force citizens to engage in commerce, saying, “If Congress can penalize a passive individual for failing to engage in commerce, the enumeration of powers in the Constitution would have been in vain."

The fact that Judge Vinson ruled against the bill is not as surprising as how strongly he ruled against it. While the previous rejection of the bill called for changes in parts of the act, Judge Vinson claims that the insurance mandate invalidates the entire bill.  The insurance mandate is so ingrained in the other stipulations of the bill, Judge Vinson feels the entire reform must be ruled unconstitutional.

As the Affordable Care Act winds its way through the appeal system, the existence of the reform remains to be seen. Will parts of the bill be changed or will the entire reform be ruled unconstitutional? Should Congress have the right to mandate the purchase of health insurance? Or is that a decision best left to the free market?

As always, comments are welcome and appreciated. Let's hear it. 

Government Drugs

No one is discovering new drugs and the U.S. government has something to say about it. The New York Times wrote an article in January about the NIH breaking into the business of drug discovery. In October of 2011 the NIH will launch its "National Center for Advancing Translational Sciences."

The center will use screening to find chemicals that act on enzymes to create new drugs and cures. Once these chemicals are discovered, the center will also be responsible for animal testing and clinical trials---all functions usually undertaken by pharmaceutical & biotech companies in the private sector. All of this will happen with an initial investment of one billion dollars.

So why would the NIH start doing something its never done before? Because someone has to do it. The past decade has been marked by minimal drug discovery in the private sector. Add this to the fact that pharmaceutical companies are cutting research and you have a medical community that is desperate for new answers.


 Issues I Foresee:

1) The Learning Curve: The drug discovery process is long and extremely involved. Major pharmaceutical companies have been working on the process for years; they know it. The time from initial discovery to market is often 15-20 years (See Diagram Below). Jumping head first into a process which takes that long could prove frustrating.

2) The Funding: The center is starting out with an initial investment of one billion dollars. A single drug can cost up to a billion dollars to discover. It begs the question: will there be more funding eventually? Because they will need it.

Is drug discovery something the government is obligated to undertake? Will the NIH's attempt at drug discovery flourish or flop with the rest of the pharmaceutical companies? Let's hear what you think.