Category Archives: General Health

Care Coordination and Magical Thinking

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One myth that has been promulgated has been that care coordination will lead to cost containment. A commentary on this topic (JM McWilliams. NEJM 2016; 375: 2218-20) explains the fallacy of this thinking.  While care coordination can improve medical care, “conflating cost containment and care coordination poses many potential dangers.”  Good care is worthy goal even in the absence of saving money.

Key points:

  • Care coordination often improves outcomes but typically involve interventions to correct underuse of care
  • For every costly complicated prevent, “a care coordination program must manage care for multiple patients…[which] is costly.”
  • Early evaluation of care coordination in accountable care organizations (ACOs) have shown the efforts “have meaningfully improved patient experiences but not rates of hospitalizations for ambulatory care-sensitive conditions.” There has not been evidence of fewer readmissions or fewer preventable hospitalizations with care coordination.
  • Other strategies to reduce cost are now being targeted, like steering patients to lower-priced providers

My take (from author): “We should coordinate care not to save money but because coordinated care is better care.”

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Yellowstone (I took this picture!)

Can the FDA stop snake oil salesmen?

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A recent commentary (C Robertson, AS Kesselheim. NEJM 2016; 375: 2313-5) examines how the issue of “free speech” may undermine the FDA’s ability to regulate ineffective or dangerous medications. This has been discussed in a previous blog:

Can the FDA prohibit free speech?

In a previous case, Caronia had promoted sodium oxybate for a wide range of nonapproved uses; some of these uses “were likely to cause patients substantial harm.”

Yet, the 2nd Circuit court reversed a lower court in ruling that Caronia’s sale pitches were protected free speech.  This decision “subverted decades of presumptions about how the government could oversee the behavior of the pharmaceutical and medical device industries.”

The authors hope that an upcoming case to the 1st circuit will uphold the FDAs ability to assure that patients are protected and that the use of drugs is driven by science and not marketing.  If manufacturers are allowed to promote a wide range of uses for drugs with narrow indications, there will not be an incentive to determine if these medications are safe and effective.

My take: If the principles of free speech are extended to promoting bogus claims about pharmaceuticals and medical devices, this would be a huge blow to medical science.

Acadia Natl Park

Acadia Natl Park

Gut Makeover -A New Years’ Resolution?

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A recent NY Times article reviews a recent study which shows that changes in diet that incorporate more fruits and vegetables appears to create a ‘healthier’ microbiome.

Link: A Gut Makeover for the New Year?

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An excerpt:

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Related article: VJ Martin, MM Leonare, L Fiecntner, A Fasano. J Pediatr 2016; 179: 240-48.This review provides more specific information regarding the microbiome in health and disease.  Specifically, the authors provide data on the relationship of the microbiome to five common pediatric chronic inflammatory conditions: allergic diseases, celiac disease, inflammatory bowel disease, necrotizing enterocolitis, and obesity.

Related blog posts:

 

NEJM Critique of the HHS Pick: Forsakes Tradition of Looking Out for Vulnerable

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A recent NEJM commentary reviews Dr. Tom Price’s congressional record and the implications for his impending appointment to head HHS.

Full Text: Care for the Vulnerable vs Cash for the Powerful –Trump’s Pick for HHS

Here’s an excerpt:

Ostensibly, he emphasizes the importance of making our health care system “more responsive and affordable to meet the needs of America’s patients and those who care for them.”4 But as compared with his predecessors’ actions, Price’s record demonstrates less concern for the sick, the poor, and the health of the public and much greater concern for the economic well-being of their physician caregivers…

Price has sponsored legislation that supports making armor-piercing bullets more accessible and opposing regulations on cigars, and he has voted against regulating tobacco as a drug. His voting record shows long-standing opposition to policies aimed at improving access to care for the most vulnerable Americans. In 2007–2008, during the presidency of George W. Bush, he was one of only 47 representatives to vote against the Domenici–Wellstone Mental Health Parity and Addiction Equity Act, which improved coverage for mental health care in private insurance plans. He also voted against funding for combating AIDS, malaria, and tuberculosis; against expansion of the State Children’s Health Insurance Program; and in favor of allowing hospitals to turn away Medicaid and Medicare patients seeking nonemergency care if they could not afford copayments.

Price favors converting Medicare to a premium-support system and changing the structure of Medicaid to a block grant — policy options that shift financial risk from the federal government to vulnerable populations.

My take: I’m worried that patients who need even basic care may not receive it if the affordable care act is repealed without a backup plan in place.

Related NY Times article discusses Dr. Price: Trump’s Health Secretary Pick Leaves Nation’s Doctors Divided The article discusses the AMA’s endorsement of Dr. Price and how many physicians have countered that the AMA does not speak for them.

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How to Undermine Value Care: Lessons from Pharmaceuticals

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A brief commentary (LS Dafny et al. NEJM 2016; 375: 2013-15) helps explain how easy it is to prevent high-value care.  The authors note that one example of encouraging high-value care is to tier drugs in insurance plans.  Insurers can encourage consumers to use drugs that provide high value by providing lower copays (lower tier) and at the same time this allows the insurers some leverage with pharmaceutical manufacturers in negotiating prices of their medications.  Roughly 75% of insurance plans have at least three drug tiers.

The pharmaceutical companies have “counterattacked” by offering “copayment coupons.”  Since insurers still pay ~80% of the costs, even with these coupons, the manufacturers are able to shift spending to higher-priced medications and still make a considerable profit.  The net effect of copayment coupons:

  • “reduce the incentive for drug manufacturers to offer price concessions in exchange for preferred tier placement.”
  • With these coupons, the strategy of charging “insurers the highest price possible while remaining on the formulary” takes hold
  • The number of these “copayment coupons has skyrocketed.” By 2010, approximately half of brand-name drug revenue was derived from drugs with copayment coupons.
  • “We estimate that coupons increase the percentage of prescriptions filled with brand-name formulations by more than 60%.” Among 85 drugs facing generic competition, “between 2007-2010, the 23 drugs with coupons likely was between $700 million to 2.7 billion higher than it would have been” without these coupons.

The authors note that health care providers may ultimately pursue similar pathways to try to get around insurance companies preferred provider panels.  This could occur as insurance companies increasingly try to control costs by demanding steep discounts from providers in exchange for inclusion in more limited networks.

My take: Providing high value care is not the chief concern for private industry. Both the insurance companies and the pharmaceutical companies develop policies and countermoves to further their best interests.

Related blog posts:

Jones Bridge Trail

Jones Bridge Trail

 

The President-Elect and the Anti-Vaccine Crowd

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Multiple sources have reported that the anti-vaccine crowd is pleased with the results of the 2016 presidential election.

From Slate (11/22/16): Trump reportedly assured vaccine skeptics of of his support

An excerpt:

The president-elect has a long history of vaccine misinformation; he first began to express his beliefs that there might be a relationship between vaccines and autism nearly a decade ago—years after this association was scientifically discredited. He’s repeated these ideas over the years, and he never found it necessary to correct or refine his position during the election…

Jennifer Larson, CEO of the autism-focused Holland Center, in which she explained that she and other vaccination skeptics discussed their concerns with Trump at a donor event in August. According to her account, Trump assured them that he’s on their side.

From StatNews (11/30/16): Meeting with Trump emboldens anti-vaccine activists, who see an ally in the Oval Office

An excerpt:

“For the first time in a long time, I feel very positive about this, because Donald Trump is not beholden to the pharmaceutical industry,” movement leader Andrew Wakefield told STAT in a phone interview…

A former doctor whose medical license was revoked, Wakefield launched the movement to question the safety of vaccines nearly two decades ago with a fraudulent study (which has since been retracted) suggesting that a widely administered vaccine against measles, mumps, and rubella can cause autism…

Those who seek to undercut trust in vaccines “see in Donald Trump a fellow traveler — someone who, like them, is willing to basically ignore scientific studies and say, ‘This is true. Vaccines cause autism because I believe it’s true,’” said Dr. Paul Offit, the head of the infectious diseases department at Children’s Hospital of Philadelphia.

My take: There is a reason anti-vaxxers see Donald Trump as a fellow traveler.

Acadia Natl Park

Acadia Natl Park

Nonpartisan Fear of GMOs

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A recent NPR report: Americans Don’t Trust Scientists’ Take On Food Issues

This reports how frequently misinformed the US public is about is about food safety issues but at least this information is not associated with partisan political views.

An excerpt:

39 percent of the survey participants believe that genetically modified foods are worse for your health than non-GM food. However, there’s essentially no scientific evidence to support that belief — a conclusion confirmed most recently by a National Academy of Sciences report…

Americans believe that there’s no scientific consensus on GMOs. Just over 50 percent of respondents believe that “about half or fewer” of scientists agree that GM foods are safe to eat. Only 14 percent’s beliefs match the reality — that “almost all” scientists agree that GM foods are safe to eat…

Roughly equal shares of Republicans and Democrats (39 percent versus 40 percent) feel that GMOs are worse for people’s health. More Democrats than Republicans (60 percent versus 50 percent) believe that organic foods are healthier. It’s significant, but not a huge difference….

Related posts:

Here’s another related link: NY Times Stop Bashing GMO Foods

Ft Knox, Maine

Ft Knox, Maine