Thursday, May 28, 2009

Why our health care costs are so high and what we can do about it

In order to truly stabilize the economy and rescue Medicare from financial collapse, the Obama administration knows it has to do something about the elephant in the room: ever-rising health care costs. In this week's New Yorker, surgeon-writer Atul Gawande presents an eye-opening discourse on why American health care costs have ballooned in the last decade and what can done about it.

To make his case, Gawande visits McAllen, Texas, which is one of the most expensive health-care markets in the country. In 2006, Medicare spent $15,000 per enrollee in McAllen (almost twice the national average); only Miami, Gawande reports, spent more per person on health care. The reason? Too much medicine. Doctors in McAllen prescribe far more tests, treatments and surgery than doctors in a nearby Texas town and nationwide. Yet the quality of health care is no better in McAllen, and Gawande cites research showing that such overuse of medicine may actually make patients worse.

So why are doctors in McAllen so aggressive? After interviewing everyone in sight, Gawande concludes that many doctors in this Texas town, unlike doctors in more conservative cities like Seattle, Sacramento, Boise and even nearby El Paso, see their practice as a money-making "revenue stream." They recognize that the more tests and treatments they prescribe, the more procedures they do, the more money they'll make.

The solution? Gawande argues that rather penalizing the money-savvy docs of McAllen, the Obama administration should begin rewarding the doctors and non-profit institutions (hospitals like the Mayo Clinic and health plans like Intermountain and Kaiser) that band together to practice a more preventative, conservative type of medicine and discourage "overtreatment...and sheer profiteering."

Gawande notes that "we are witnessing a battle for the soul of American medicine" and concludes that unless we begin rewarding "the leaders who are trying to a build a new generation of Mayos...McAllen won't be an outlier. It will be our future."

This is a scary article and a must read.

Wednesday, May 20, 2009

Denis Maltez is the reason we need to know who is shilling for Big Pharma

On his Pharma Marketing blog today, John Mack recaps the controversy over the patient who was paid hundreds of thousands of dollars by Bristol Myers Squibb to promote Abilify and then changed his tune. (Andy Behrman, aka "Electroboy," began talking out about the serious effects he had suffered while taking the anti-psychotic). In his blog, Mack asks the question: “Is this done often by all pharmaceutical companies or is it just something unique to BMS?”

Why do I have the feeling that Mack already knows the answer? It's not exactly a state secret that drug companies routinely pay doctors and patients, the higher the profile the better, big bucks to hawk their drugs. Look at Bob Dole and Viagra, heart doctor Robert Jarvik and Lipitor. The list goes on and on. The drug companies would, of course, prefer to pay key opinion leaders in medicine (KOLs as they are known) and celebrities to promote their wares, but they will pay anyone whom they think has a shred of credibility with the population they are trying to target. As I reveal in Side Effects and on my blog, a number of drug giants including Eli Lilly, GlaxoSmithKline and Pfizer paid Jim McNulty, past president of the National Alliance for the Mentally Ill (NAMI), thousands of dollars to promote their antidepressants. In his talks around the country, McNulty billed himself as a patient since he took the drugs to combat bipolar disorder. But he never disclosed to his audience or the members of NAMI that he was getting all this money on the side from Big Pharma.

So why does this matter? For an answer, one has only to read the heartrenching story in The Miami Herald today about yet another young boy in Florida who died after being given a cocktail of potent psychoactive drugs. According to a wrongful death lawsuit filed by his mother, Denis Maltez, 12, who was living a state-funded group home and had been diagnosed as autistic, was on Seroquel and Zyprexa (atypical anti-psychotics), as well as Depakote, an anti-seizure drug, and Clonazepam, a tranquilizer. Denis apparently died of serotonin syndrome, according to a 2007 autopsy by the Miami-Dade Medical Examiner’s office. As reported in The Herald, that condition occurs when a combination of drugs causes the brain to produce an excess of serotonin, a neurotransmitter in the brain.

Maltez’s mother says she sent her son to the group home after he tried to choke his younger sister. Her lawsuit comes in the midst of a high-profile investigation by Florida authorities into the death last month of a 7-year-old foster child who had also been taking a cocktail of psychoactive drugs.

Why, you might ask, do some psychiatrists prescribe these potentially lethal drugs to young children and then not monitor them for side effects? I can't answer that question. What I do know is that many doctors and consumers think these drugs are safe and effective for such off-label uses in large part because drug companies have paid big bucks both to KOLs and "patients" like Andy Behrmann and Jim McNulty to shill for them. And that's precisely why we need public disclosure laws like the one that the Vermont Legislature passed this week -- see New York Times article here -- so that everyone knows who the shills are and can take what they say with a hefty dose of skepticism. Here's hoping Congress passes the Physician Payment Sunshine Act and makes this a national trend.

Thursday, May 14, 2009

Senior citizens wising up to Big Pharma

I had the pleasure of speaking to a large group of senior citizens yesterday at a Jewish community center in the Boston area. I had been invited there to talk about Side Effects, and while the focus of my talk (like my book) was how drug companies deceived the American public about the safety and effectiveness of SSRI antidepressants in treating children, the seniors very quickly made the leap to how this issue affects them. During the Q&A, a number of them spoke up about the difficulties they’d had in getting a straight answer out of their doctors about potential side effects. They talked candidly of their confusion in not knowing whom to trust and where to get accurate, objective information about the drugs they were being prescribed.

This was a savvy, educated bunch of people, mostly in their 70s and 80s, and it was clear they took the business of their health seriously. A number of those in attendance said they didn’t always accept their doctor’s word that a particular drug was safe, and they seemed to have no problem understanding how pharm-bred gifts, free meals, junkets, not to mention lucrative consulting and speaking fees, could compromise the most devoted doctor's judgment.

One woman, for example, told me that two different doctors in recent months had prescribed neurontin, a drug approved for epileptic seizures, to ease her chronic pain, even though there is little scientific evidence it works as a painkiller. Indeed, four years ago, Pfizer paid a whopping $430 million fine for illegally marketing neurontin for off-label uses such as pain and anxiety. (The drug company essentially paid academics to put their names on research papers prepared by the company to promote these uses – shades of the Vioxx court saga currently shadowing Merck). Fortunately, the woman at the JCC had taken the time to ask around about neurontin and a family member who is in the health care field discouraged her from taking the drug. So she didn’t. She found a safer and more effective alternative.

In fact, I was surprised at the level of skepticism these seniors seemed to share about their doctors and the medical establishment as a whole. And it made me think: If this age group, which has witnessed some true miracles in medicine over their life span, is so cynical about the current state of health care, perhaps the time really is ripe for reform, and I’m not just talking about reform in the way medical care is paid for and delivered, but also in how new drugs and medical devices are tested and brought to market.

Indeed, it appears as if the senior set has already taken matters into their own hands. According to Medco’s annual report on drug spending, released yesterday, spending on drugs actually fell among people age 65 and older. Medco attributed the drop in spending among this age group to its increased use of generic drugs. Now maybe this has something to do with the economic climate, but it could also be attributed to the fact that senior citizens, along with other consumers, are wising up to the misleading blandishments of the pharmaceutical industry. And at the risk of generalizing from the comments and questions I heard yesterday, it appears as if they want their doctors to wise up too.

Thursday, May 7, 2009

The media storm over swine flu: one more reason why good health journalism matters

As The Boston Globe's unions vote on whether to bow to the inevitable and make the financial concessions demanded to keep their newspaper alive, it seems a sad but apropos time to bring attention to a new survey on the declining state of health care journalism. The survey, authored by Gary Schwitzer, a professor at the University of Minnesota School of Journalism and founder of the Schwitzer Health News Blog, shows how financial pressures on the media are hurting the quality of health care reporting.

Health care journalists themselves are the first to acknowledge this disturbing trend. Fully 94 percent of the reporters interviewed agree that media downsizing has seriously hurt the quality of health news coverage. Here are some of the other key findings of the survey, according to Hot Topics in Journalism and Mass Communcation :

• Forty percent of the reporters surveyed say the number of health reporters at their organization has gone down since they’ve been there, and 11 percent say they personally have been laid off over the past few years due to downsizing.
• Nearly nine in ten respondents think health care coverage leans too much toward short “quick hit” stories, and two-thirds say the trend toward shorter stories has gotten worse in the past few years.
• A majority of respondents say there is too much coverage of consumer or lifestyle health, and too little of health policy, health care quality, and health disparities.
• Just under half of the journalists surveyed say that their organization sometimes or frequently bases stories on news releases without substantial additional reporting.

And if all of that is not alarming enough, here’s a really scary finding:

• About one in 10 journalists in the survey say his or her own organization sometimes or frequently allows advertisers, sales staff or sponsors to influence story selection or content. Yikes! What's happening to the separation of editorial and business -- a bedrock principle of journalism?

You might ask: why does any of this matter? For the answer, one has only to look at the difference in the way media organizations have covered the current swine flu outbreak. While newspapers with experienced health reporters like The New York Times and The Boston Globe provided thoughtful and measured coverage of the epidemic, other media outlets have been less circumspect. Here’s some interesting commentary by Stacey Woelfel, chairman of the Association of Electronic Journalists, berating her fellow television journalists for sensationalizing the current outbreak and literally beating the story to death in the race for ratings.

Despite such sensationalistic coverage, health officials in the current administration have so far refrained for insisting that Americans get inoculated against the latest flu strain. Perhaps the public health community learned its lesson from the last swine flu scare in the 1970s, when the Ford administration ramped up production of a poorly designed vaccine. In the end, the vaccine ended up killing and crippling more people than the flu itself.

The 1970s debacle is precisely why good health coverage matters. We need experienced science and medical journalists who can provide the kind of accurate and authoritative coverage that allows policy makers to make wise decisions about the public's health. This time around, the nation's top health advisors managed to ignore the media cacophony and do what they thought was right. Next time, we may not be so lucky.