Pizza and Prescriptions.

We’ve talked about doctors receiving honoraria and other payments from drug companies to influence their choice of treatments.  Always quite righteously physician groups have responded to such allegations with drivel about their professionalism and their over riding concern for their patients.  That works up to a point but in our culture money talks.

This puts such arguments to rest:

As little as one free meal from a drug company can influence which medicines doctors prescribe for Medicare patients, according to a study using Medicare records and recently released data from the health care law’s Open Payments program.

More here.

Medicynical Note:  For the almost 50 years that I’ve been a physician drug companies have vied for face time with physicians.  Some of it is fairly legitimate education on new better drugs but most is simply  a sales pitch to get the doc to change his/her prescribing habits, almost always with limited benefit and  increased cost.  Various incentives are provided to get this access–cash payments, meals, faux jobs, deals on medications given directly to patients.  It all works and it all costs the system integrity and cash. 

But hey that’s the way America works. Check out the gun lobby and the recent assault weapons votes.  Money buys access and influence.  Doctors are not immune. 

Your Money or Your Life: America’s Health Care Disaster

It used to be financial planning was a field which provided assistance for the golden years (retirement),  In the U.S. financial planning is necessary for patients to get their health care.  Our amazingly inefficiency expensive (most in the world) health care non-system is now providing such planning to patients to “help” finance their care.  Something is terribly wrong here.

His doctor had prescribed the cancer drug Gleevec, but Steiner’s insurance refused to cover its $3,500 monthly cost. Steiner, a warehouse manager for a publisher of Bible-themed literature, and his wife, Brenda, a part-time nurse, made just $30,000 a year. No way could they afford the drug on their own.

“We still had six kids at home — how were we going to come up with that kind of money?” Steiner said. “We couldn’t re-mortgage the house, because it had already been re-mortgaged. I wouldn’t have been able to take the medication. We would have had to just trust in the Lord.”

It was a scary brush with “financial toxicity,” as researchers call the mix of economic stress, anxiety and depression cancer patients often endure. But then Steiner was assigned to Dan Sherman, an oncology social worker at Mercy Health Lacks Cancer Center who within days got a free supply of Gleevec from the manufacturer. He also made sure it was delivered promptly. The package arrived at Steiner’s home on Christmas Eve, his 46th birthday.

In the eight years since, Steiner has faced a series of medical and financial reversals, and each time Sherman has done as much as any doctor to keep Steiner going — scrambling to get the treatment he needed without sending his family into bankruptcy. “He keeps throwing me life rafts before I sink,” Steiner said.

Read the entire article.

Medicynical Note:  Health care in the U.S. is a special type of hell if you are not independently wealthy.  Something like 60% of bankruptcies in our country are related to medical expenses and it appears from the above article that the first goal of our non-system is to spend all the patient’s savings and then offer assistance.

Our insurance companies’ main goal is to assure profits to share holders, hospitals have a multilevel billing system which ironically bills most those without insurance coverage and least able to pay;  our drug companies think nothing of gouging patients to pad their bottom line, because they can (pretty sadistic); and our medical practitioners often are on their receiving end of payments from technology providers to get them to use the company’s product.  Care of patient is not the primary concern of many in our health care industry.

There are bright spots.  People working to help patient’s figure out the non-system; primary care types working very hard for relatively (compared to some medical specialties) low salaries; our nursing and medical support colleagues who work face to face with patients helping with their care and problems, medical and otherwise.  

The Affordable Care Act is a good first step but more needs to be done.  

Limits– Drug Pricing in the U.S.

Drug prices are a prime example of the monetization of medical care.  The price of drugs is currently based on the ability of the manufacturer to increase it (exclusivity and lack of competition) and the seriousness of the person’s illness (the more dreadful the illness the higher the price).  The cost of research of course is an issue, but when Pharma raises the price of generics hundreds percent you know that it’s all about profit and that the costs of drug development has nothing to do with it.

It is a fact that the fiduciary responsibility of the drug manufacturer is to the stock holder not to the patient.  So costs skyrocket and we in the U.S. pay more for everything medical than anyone else in the world.  Are we dumb or simply naive.  We seem to buy into drug company and politicians propaganda that we have the best of all worlds, when we don’t.

This in the JAMA gives some perspective

The rate of increase in drug prices has outpaced that of overall medical care every year since 2008. A recent survey found that retail prices of selected brand-name dermatological medications increased an average of 401% between 2009 and 2015 (363% in real terms, accounting for inflation), while prices of the generic medications increased an average of 279% between 2011 and 2014 (265% in real terms). These price increases for dermatological drugs are well above the national average for all drugs and payers—up 23% in real terms between 2009 and 2015. They do not reflect the possibilities that patients might switch to cheaper alternatives, or there may be slower growth in prices paid by insurers and public programs.

Retail prices have increased dramatically for other types of drugs, as well. The aggregate retail price of a basket of 477 widely used drugs doubled between 2006 and 2013, even though retail prices for generics decreased. Per life-year gained, new anticancer drugs prices have quadrupled in 2 decades and now exceed conventional levels of cost-effectiveness.

And

Constraining prices so more drugs are cost-effective—for example, below $100,000 per quality-adjusted life year—is one approach to managing drug price inflation. Although the political prospects for such a policy are poor, recent value-based contracts between manufacturers and insurers or pharmacy benefits management companies are similar in spirit. For example, Cigna’s payments to Novartis for the heart failure drug Entresto are linked to how effectively it reduces hospitalization.

Medicynical Note:  The article follows with a discussion of how much we as a society can pay for drugs.  Frakt seems to accept that $100,000/QALY is doable and posits that perhaps we can pay even more–though not much.  On the other hand one can reasonably argue that we’ve already exceeded our ability to pay and that for a QALY drugs for a year’s treatment should at a maximum cost no more than a our culture’s median or average income for a year –that is $50,000-60,000.  And that may be too expensive.  Read the article!

Medical Alchemy: Valeant again, Seconal

America’s uniqueness lies in part in the fiction that free markets work and that the “music of the marketplace” will unerringly do the “right thing.”

As medicine became monetized (def: is the process of converting or establishing something into legal tender) in the U.S. it’s fiscal processes have become more grotesque.  We have medications on the market that big Pharma sells at many multiples of the median and/or average income of our citizens.  Most of these drugs have minimal to moderate effect on the ultimate course of diseases.  And even if completely effective can we afford medications at such multiples of our incomes? 

In recent years the fad in monetization has been buying old drugs and rapidly increasing their prices.  The old cover of we need to charge a lot to pay for research falls by the way side as these companies simply charge whatever they can because they own the drug.  No research is necessary it’s simply a monetary play, as in “The Big Short.”  Patients well being is simply not their concern.  In health care today, it the money stupid.

The issue arose last year, when Valeant Pharmaceuticals International of Quebec acquired the rights to Seconal, the trade name of secobarbital sodium, the most commonly prescribed drug for aid-in-dying patients. The firm quickly doubled the cost, from $1,500 to more than $3,000 — and up to $5,000. That’s on top of previous retail price increases for the nearly 90-year-old sedative that once sold for $150 for a lethal 10-gram dose.

Medicynial Note:  Yes the article describes the fix for the price increase, as new concoction which while effective is likely not as ideal as the secobarbitol (seconal).  But consider this, a drug that was patented in 1934 and at one time cost pennies a dose (for sleep) and as recently as 30 years ago cost in the range of $50-$100 is now priced at  $3000.  Alchemy?   An American success story? Or part of the continuing demise of our health care non-system? 

Poster Boy: In Defense of Martin Shkreli, the useful tool

Understand that Martin is the poster boy for the corruptish practices in what was once a self proclaimed “ethical” industry.  In fact the pharmaceutical industry, Big Pharma in the United States, has always run close to ethical boundaries.  Going back to my graduation from medical school, who was there to take the senior class to an expense paid weekend in New York? Why none other than that “ethical” company Ely Lilly.  Some might have called this a conflict of interest for both the new docs and the “ethical” company but when you are a poor struggling senior medical student you are easily bribed.  To this day doctors are targets of drug companies often receiving various forms of payments for either their continued use of products or for listening to the spiels of drug salesmen.  In this relationship there is a very narrow line between legitimate product education and payment for services.

Throughout the next 48 years of my professional life  this so-called “ethical” industry did everything to protect and improve its position.  They have one of the strongest lobbys in D.C., having most of the congress on their payroll—facilitated by our Supreme Court.   In that time we have seen medicine change from an ostensibly doing good industry into a doing well industry.  Patients no longer are viewed as sick people but rather customers for various product lines.  Drugs are no longer developed to help patients but rather to improve company’s bottom lines and yes the sicker the patient the more we can charge, regardless of the cost of drug development.

Getting back to our stooge Shkreli, he has been the focus of our ire for his raising the prices of medications that his company has bought the rights to.  He  gleefully accepted the criticism and cynically shows no contrition.  But consider that his behavior  is standard for the drug industry; that Big Pharma has been gouging U.S. consumers for years; that his companies governing boards have approved of his actions (only removing him because of his alleged earlier criminal behavior).

Some examples of drug company gouging and misbehavior can be found by simply reviewing Medicynic’s archives but to make it easy with a quick googling I came up with these examples.

http://www.businessinsider.com/john-oliver-takes-down-prescription-drug-industry-2015-2

https://projects.propublica.org/docdollars/

http://health.usnews.com/health-news/patient-advice/articles/2015/07/15/how-doctors-make-money-from-drug-companies

http://www.huffingtonpost.com/entry/americans-pay-more-for-drugs-than-anyone-in-the-world_561bda8fe4b0e66ad4c89449

http://money.cnn.com/2015/10/09/investing/drug-ceo-daraprim-price/

http://www.wsj.com/articles/pharmaceutical-companies-buy-rivals-drugs-then-jack-up-the-prices-1430096431

http://www.bloomberg.com/news/articles/2015-09-23/how-marketing-turned-the-epipen-into-a-billion-dollar-business

http://www.wallstreetotc.com/serious-price-increase-for-generic-drugs/212724/

http://www.wallstreetotc.com/serious-price-increase-for-generic-drugs/212724/

Medicynical Note:  And it’s not just generics increasing in price.  New patented cancer drugs start their pricing now at $10,000/month and increase at rates often over 10% a year.  For example, Gleevac (imitinab), a drug for chronic myelogenous leukemia,  was released in 2000 at a price of around $40,000/year it’s now three times that price.  Drug  prices are based on whether there is an alternative and how sick the patient is, not the cost of development.  The fewer the options and the sicker the patient the higher the price.  And yes in the U.S., being the perfect fools, we pay much much more for drugs than anyplace else in the world.  Why?  Because Big Pharma has abused the system and induced  congress to ignore their abuses.

Instead of damning the clown Shkreli, we should be thanking him for bringing the price gouging of Pharma to our attention.  Will anything be done?  For good reason I’m a medicynic, so I don’t think our congress is capable of intervening.  They don’t bite the hands that feed them.  Sad, but that’s American Exceptionalism.

American Health Care Fail: Increased Death Rate Among Poor Whites Aged 45-54

The Proceedings of the National Academy of Sciences reported a disturbing study showing an unprecedented increase in the death rate among white citizens with the least education.  The details of the study were reviewed in the American Prospect.

The increased deaths were concentrated among those with the least education and resulted largely from drug and alcohol “poisonings,” suicide, and chronic liver diseases and cirrhosis. This midlife mortality reversal had no parallel in any other industrialized society or in other demographic groups in the United States.

Case and Deaton’s analysis, published today in the Proceedings of the National Academy of Sciences, also shows increased rates of illness, chronic pain, and disability among middle-aged whites. The findings have important implications for American politics and public policy, particularly for debates about economic inequality, public health, drug policy, disability insurance, and retirement income. The data also suggest why much of American politics may be taking on an increasingly harsh and desperate quality

The study points out that the U.S. is unique in that no other of the western industrialized nations is having a similar spike in mortality.  Read the entire American Prospect article for details.

Medicynical Note:  Hard to make a clever cynical comment about a study that focuses our attention on the failure of our culture to address it’s most basic needs.  We appear to have a problem not only with health care but with the very basis of our culture…..capitalism. 

Daraprim/Turing Isn’t Alone, Shkreli learned from others

Health care is delivered  by an industry more interested in financial return than access, quality of care, efficiency or value.  It has become a financial play.  As an industry it offers a customer base that is desperate; products often with limited to no competition; and a market that’s protected by patents and a disinterested (paid off) congress.

But Shkreli isn’t the only abusive drug company CEO.  Consider these:

Gal pointed to three examples: Jazz Pharmaceuticals’ drug Xyrem, Questcor’s Acthar and Mylan’s EpiPen.

And

The company reported revenue from Xyrem of $29 million in 2006, the first full year after its acquisition. Last year, Jazz posted Xyrem revenue of $778.6 million.

While the company said it’s expanded the number of patients the drug treats, the cost also increased an average of 29 percent a year from 2011 to 2015, according to data distributed this week by Evercore ISI analyst Mark Schoenebaum.

And

H.P. Acthar Gel was initially approved in 1952, the year before Turing’s Daraprim, the subject of this week’s controversy. It treats infantile spasms and exacerbations of multiple sclerosis in adults, among other indications, and its price, as The New York Times reported in 2012, hopped from $1,650 to $23,000 a vial on a single day in 2007.

And

EpiPen, used in emergency treatment for life-threatening allergic reactions, is sold by Netherlands-based drugmaker Mylan. The price, according to data from Evercore ISI, increased 27 percent a year, on average, from 2011 to 2015, to more than $300 each dose.

Medicynical Note:  The only coherent explanation of what’s happening is that these robber barons have  cornered the market and are gouging for all they are worth…oh I mean all WE are worth.  Our health care non-system is uninterested in cost containment or for that matter delivering value because as the costs go up everyone’s share of the pie increases.

Except maybe for the doctors who are, ironically, the low men on the totem pole of the health care hierarchy.  It’s terrifying that the high men are hedge funders with only one interest, and it ain’t health care.