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QUALITY QUICKIE: Practice Variation by Race

Researchers in John Wennberg’s shop at Dartmouth have come out with another stunning analysis of practice variation published in the new England Journal of Medicine (NEJM). This time it’s not region that makes a difference, but race of the patient. Essentially the article says that you are much less likely to receive a common type of knee surgery if you are black or hispanic than if you are white.

We’ve know for a long time that outcomes and health status are impacted by race and socio-economic status (SES).  For instance black males in Harlem have much lower life expectancy than average.  Similarly, despite the 50 years of Universal Health Insurance and care from the National Health Service in the UK, SES or "class" level there has a marked impact on health status and outcomes. In fact variation in employment status within the same SES, also has a large impact (and not surprisingly it’s better to be at the top than the bottom), as shown in the classic British Whitehall Study. And of course we also know that access to care for those without insurance is worse in the US than for those with insurance.

However, I believe that this is the first example in the US showing that access to a specific type of care for those in the same insurance category is very different.  I don’t know why black seniors in the US have knee surgery at half the rate of white seniors.  I suspect both patient demand, and physician culture have something to do with it.  I also don’t know which rate of knee surgery is better.–especially as last year the NEJM published a study that said that in the case of osteoarthritis, knee arthoscopy was no better than placebo. But it is clear that race and presumably other social factors influence the treatment that is given to patients with similar conditions for no good reason.

(Alerted to this by California Healthline)

TECHNOLOGY: New tools for e-detailing

The crush of detail reps all trying to break into the physician office has been causing headaches for some time.  Not only for the poor office staff but also for their pharma company CFOs.  Although Pfizer’s success in the past decade has been based mainly on expanding its field sales force, the truth is that detail reps rarely get more than one or two actual presentations in to doctors per day.  Most of their time is spent sitting in the waiting room, and hence the need to deliver cookies, tickets to sporting events, dinners and other bribes knowledge-enhancing opportunities to physicians. Now that PhRMA and the AMA have "agreed" to new guidelines restricting what a detail rep can give to a doc, the physician’s incentive to see the rep has declined even further.  Meanwhile eDetailing may provide some answer to getting the message out. (For much more information on the eDetailing market see here) Manhattan Research reported recently that (some fraction of) 49% of doctors were likely to use eDetailing. (Note: I don’t have the full numbers, so I’m extrapolating somewhat vaguely here).

The problem has been getting some technology that’s easy and convenient in front of the docs. Companies like iPhysiciannet and RxCentric have taken a high bandwidth approach, including sometimes actually putting IDSN lines and computers in physicians offices. But they have often required an actual appointment time, which is a pain in the rear and an actual cost for a busy doc. And, of course, it’s pretty expensive.

On interesting new approach for eDetailing is a tool called Av-Mail. This allows a pharma co to send an email to a doc.  At a time and place of their choosing, physicians can click on a link on the email, and view a relatively short combined powerpoint/voice-over presentation.  Click here to see what it’s like. Something like this might be a reasonable answer to getting in front of docs at very a low cost.  How effective it is in increasing script writing I don’t know, but I suspect it’s not as much fun as a free trip to Hawaii.

THE INDUSTRY: Price Discrimination lives–Only the poor pay full price in U.S. healthcare system

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In an article on CBS Marketwatch, titled Only the poor pay full price, Michael Collins points out from a business point of view, the crazy pricing scheme in the U.S. healthcare "system". I had a similar experience last year when I had knee surgery.  I bargained heavily with my surgeon who wouldn’t take managed care contracts.  For the facility charge, the bill I saw was $20,000 but the facility only collected around $8,000.  Meanwhile a surgeon billed me over $100 for a second opinion, but the PPO only paid $43. I remember this back in 1990 in Alain Enthoven’s class.  Several hospital representatives in the class used to complain about being forced to give managed care plans "discounts".  Enthoven called hospital billing a "fiction".

Collins makes the obvious point that if you do not have insurance, you will be charged the full price.  The provider may not expect to get their money, but if you have any assets, the hospital/clinic will come after you for the money–and you’ll be paying at the full rate, which no insurer pays. 

In fact it may be worse.  If you do have insurance and you pay 20% of the fee, your insurer may make you pay them 20% of the full fee, while they get the negotiated discount that my classmates complained about.  Several Blues plans had plenty of legal problems when they were caught doing this practice in the mid-1990s, including Trigon (Virginia) which in essence was forced to pay large fines several times over in order for the state Attorney-General to allow it to turn for-profit. (I can’t find a reference to this but it was a big deal before they could get their S1 registration out in 1996).

Transparent pricing would appear to help everyone.  But for historical reasons (the need for cross-subsidizaton within providers from rich to poorly insured patients) it hasn’t emerged. Now for business reasons, no one wants to reveal their "deal". This is as true for hospital and physician care, as it is for drug rebates, and it gives the lie to health care being a "free" market.

Healthsouth Quickie

Following onto the recent post about the problems of for-profit health services, which highlighted Richard Scrushy, HealthSouth’s CEO, in the last couple of days another former HealthSouth honcho has plead guilty to falsifying records.  For those of you scoring at home that makes 15 execs admitting guilt so far. Healthsouth ended up claiming more than $2.5 billion in false profits a la Enron.  Also today the Corporate Counsel and Corporate Secretary just quit. Cleaning up the mess can’t have been too much fun.

More details on the Medco suit

Here’s what Medco said in its IPO offering document last April:

    In February 2000, two qui tam, or whistleblower, complaints under the Federal False Claims Act and similar state laws were filed under seal in the United States District Court for the Eastern District of Pennsylvania. These
    complaints allege improper pharmacy practices, violations of state pharmacy laws and inappropriate therapeutic interchanges. We have not been served with the complaints and have not been required to defend against the allegations.

Well now that the US Attorney is joining the suit, it appears that the "practices" included
"Inappropriately filled prescriptions includ(ing) instances where a Medco pharmacist said he consulted a doctor but didn’t, or when a prescription was canceled suspiciously".  The stock market doesn’t seem to care, based on the fact that the existence of the suit was disclosed in the S1. However, the US Attorney is being very aggressive claiming that the government can charge $5000 for each script that was affected, and that there are thousands and thousands.  It’s worth keeping an eye on this one as PBMs may find their future in whatever comes out of the Medicare Drug Coverage bill is affected by this publicity–whether or not Medco is found guilty and fined a huge sum.

Did Astra Zeneca treat innocent MDs as Babes in the Wood? by Matt Quinn

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Matt Quinn wrote this post about doctors charging Medicare for samples given to them by drug companies. Astra Zeneca has already settled with the Feds at  a cost of $330m for promoting that behavior. As I’ve mentioned many time, I think Medicare’s structure makes it easy to defraud, so I don’t place all the blame on the docs.  I actually think Matt’s a little over-critical of physicians (and by extension drug companies) here.  But Matt used to work in the business of marketing oncology drugs to physicians and knows many of the tricks. So bear that in mind when you read his post below:

    A federal judge is blaming a pharmaceutical company (Astra Zeneca) for a physician, Dr. Saad Antoun, billing for (injectible) samples of their drug which he was given for free: "The judge said Antoun appeared to be ‘the kind of doctor everybody wants to go to and that this was a mistake of bad judgment fostered upon you by the drug company.‘" The full story from the Report on Medicare Compliance is here.
    My question: if this doctor is so helpless as to 1) not ask Astra directly about "misleading labeling" regarding billing for samples 2) not ask his peers/staff about the legality of billing for samples and 3) not do the (minimal) research needed to know that it violates federal law and 4) follow the directions of a drug rep in running his practice and treating his patients, how much faith should anyone have that this guy is competent in his profession?  Would it be the drug company’s fault if he used Zolodex improperly and it harmed or killed a patient?  Perhaps the label was "misleading" or the drug rep told him about an off-label use that he had heard about.
    My take is that Dr. Antoun knew exactly what he was doing — or should have.  Egregious pharmaceutical marketing only works because physicians allow it to work.  If physicians rejected trips, graft in the form of "unrestricted educational grants" and honoraria, free meals, gas, and concert tickets and other "non-scientific" aspects of drug marketing, then the companies would stop spending money on this stuff.  But many physicians don’t.  External agencies only need to regulate a profession when members of that profession can’t conduct themselves ethically.  I guess Judge Farnan can’t understand this and refuses to keep up the government’s (taxpayers’!) side of the deal.

Political update on uninsurance story

For more on the issue of how many uninsured there really are and how long they are uninsured for, go look at The Bloviator’s post. His and my conclusion is that the Census Bureau has mislabeled the 15.3% of the population that is uninsured "for the whole year." That number instead represents a snapshot of those uninsured at any one time.  Still a big number, though with many people moving in and out of it, hence a big political effect.

Regarding the political effect, my friends at Harris Interactive have given me a peek at the numbers in their classic question about the US health care system.  They have been asking the public about their view of the system forever.  When the number of people thinking that the system needs to be completely rebuilt goes above 30%, as it did in 1991 and 1992, its time to pay attention to health care politically.  Well as you can see below, its over 30% now!

2003 data from Harris Interactive:
System works pretty well/minor changes are needed: 17%
Some good things/but fundamental changes are needed: 50%
So much wrong/system needs to be completely rebuilt: 31%

Uninsurance: the numbers go way up.

It didn’t take a rocket scientist to figure it out (although The Bloviator pointed the way yesterday and he’s as smart as a rocket scientist).  An increase in unemployment plus fewer people getting health insurance at work has led to an increase in over 2.4 million people being uninsured. The New York Times article has the Census Bureau reporting that in 2002 43.6 million or 15.2% of the population were uninsured. (That’s actually down from 16.8% in 1998 before the full impact of the SCHIP program took millions of kids out of uninsurance into Medicaid, or something like it). 61.3% of Americans are covered by their or their family’s employer, and that’s down from 63.6% two years ago.

It’s worth remembering that there are three types of uninsured.  Those who’ve been uninsured for a year or more (about 6%), those uninsured at any one time (about 15%) and those uninsured at some point during a year (about 25%). (NOTE ADDED LATER The Bloviator points out that in fact the Census Bureau reports that the 15.2%/43.6 million were uninsured for the whole year. I may have missed a trick here, and I’ll report back what the 6% refers to). The 43.6 million is the middle group, which means that some 80-odd million were uninsured at some time in the past year. The political ramifications of uninsurance — and they are the only ones that matter — depend on how likely people think they are to lose their health insurance, and therefore face the risk of a financial crisis brought on by lacking health insurance.

We got to the Clinton reform process because in the 1990-2 recession enough people felt worried that losing health insurance was something that might happen to them, and not just to other people. At that stage surveys suggested that over 30% of Americans wanted a complete rebuilding of the health system.  But by the time the legislation was brought to Congress in 1994 unemployment had fallen and fewer than 20% said they wanted complete system rebuilding.  I don’t have the current numbers to that question, (although I shall go begging for them from my friends at Harris). However, health care is moving its way up the list of issues for voters, and EBRI reports that only 60% of those with employer sponsored insurance are confident that it’ll be there for them in the future (full report here), and most importantly that, "among all Americans, support for a government plan jumped from 25 to 36 percent in the past year".

I paraphrase HHS secretary Tommy Thompson’s response as "we should do better but we won’t". Meanwhile the Democratic candidates are getting serious enough about the issue to be sniping at each other about who said what when about Medicare.  This means that we are well ahead of where we were at this stage in 1991 when we still were trying to figure out who Bill Clinton was, although we didn’t then have the other minor distractions of occupying Iraq and fighting terrorism.  So expect these numbers to increase the level of grandstanding on the Democratic side, and maybe even get the White House a little concerned. Although in my biased view it looks like they’ve written off any domestic issues as a platform for 2004.

PBM quickie: Feds join lawsuit against Medco

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The Feds have backed two whistleblower suits against Medco.  The allegations claim that Medco used a variety of techniques to favor Merck (which owned Medco at the time) and was paid $430m in 2001 to switch scripts from Merck’s competitors. Back in March 2003, Milt Freudenheim in the New York Times highlighted Medco’s income from rebates (some $1 billion a year) and its ability to move share towards Merck’s drugs.

PBMs have for a long time made money from rebates, and have also been very economical with the truth to their health plan customers about how much they got from pharma companies for those rebates and how much was passed through to their customers.  However, during the late 1990s their performance seemed very ineffective in keeping down the cost of drugs for their plan and employer clients, either in reducing their usage or by holding down their unit price. For more of my take on PBMs see this post.

Interestingly enough, Medco’s stock price went up over a dollar in the latter part of the afternoon after 2pm when the confirmation (of somewhat old news) came out that the US Attorney’s office was joining the suit.

Schering Quickie

In this post a while back I wrote about the problems that mid-market pharma companies are having dealing with patent expirations.  The Jenks Health Care Report has an article on the future of Schering Plough available here , which goes into much more detail about what’s wrong at Schering and whether it can be made right.  Their view is that Schering will be dressed up for sale.  The question is, would an acquisition of a wounded company help any of the usual big Pharma suspects? Most of them have already gotten big enough in terms of sales force and market clout, so would they want Schering’s somewhat lackluster portfolio and pipeline?  Probably not at its current PE ratio of 20, which is the same as that of Bristol-Myers Squibb.  Pfizer’s PE ratio is around 50.