The Wizard Behind The Curtain – Addendum To Drive Home The Point

February 14th, 2019 by Tom Lynch

Among other things, yesterday’s post made a point about the way the PBM system (if you can call it that) makes it difficult for uninsured Type 1 diabetics to buy insulin, because of price. To beat that horse even deader, here is an excerpt from a Kaiser Health News article, in partnership with NPR, published yesterday entitled, Insulin At A Fraction Of US Cost:

Almost one year to the day after her daughter’s diagnosis, Lija Greenseid and her family were visiting Quebec City, Canada, in July 2014. Her daughter’s blood sugar started spiking and Greenseid feared her insulin might have gone bad, so she went to a pharmacy. With no prescription and fearing that her daughter’s life was on the line, Greenseid was prepared to pay a fortune.

Instead the box of insulin pens that normally costs $700 in the U.S. was only around $65 or so.

“At that point I started tearing up. I could not believe how inexpensive it was and how easy it was,” Greenseid said.

“I said to [the pharmacist], ‘Do you have any idea what it’s like to get insulin in the United States? It’s just so much more expensive.’ And he turned to me and said, ‘Why would we want to make it difficult? You need insulin to live.’”

The more Greenseid traveled with her family, the more they realized how inexpensive insulin was everywhere except in the United States. In Nuremberg, Germany, she could get that $700 box of insulin pens for $73. The same box was $57 in Tel Aviv, Israel, $51 in Greece, $61 in Rome and $40 in Taiwan.

“We get so accustomed in the United States to thinking that health care has to be difficult and so expensive that people don’t even consider the fact that it could be so much easier and less expensive in other places,” Greenseid said. “In fact, that is the case in most countries.”

Take a moment out of your busy day and think about that. Please.

And answer this question: Do you  believe America’s 1.3 million Type 1 diabetics  who require insulin every day ─ just to stay alive ─ should be forced to pay hundreds, even thousands, of dollars a month for that medicine? Or are they not worthy enough to be treated like their fellow diabetics the world over?

The Wizard Behind The Curtain – Part 2

February 13th, 2019 by Tom Lynch

Let me tell you a story.

The year is 2015, and a workers’ compensation consultant is sitting in a highly respected insurer’s plush conference room. The consultant is meeting with the insurer’s Senior Vice President of Claims to negotiate price for an innovative specialty medicine program. What kind of program? Doesn’t matter.

The consultant has come armed with pro formas showing all costs of the program. Down to the penny. The problem is the insurer and the program are miles apart on what the insurer will pay the program’s doctors for each patient encounter. The Senior Vice President says, “Look, this isn’t exactly in our fee schedule, but the closest we can come to what is in the fee schedule is to pay your folks $85 per visit.” Hearing this, the consultant once again begins to explain why the fee needs to be $150 per visit.

This goes on for another half hour. The Senior VP finally says, “Well, maybe we could go to $91 per visit, but it’s the best we can do. Take it or leave it.” The consultant offers $140, but won’t go lower, because to do so would torpedo the program, which has demonstrated far more success, accompanied by significant cost savings, than others of its kind.

And then, it happens. The Senior Vice President in that plush conference room of this highly respected insurer says, “Hang on a minute. I’ve got it. You’re a specialty program, so we have a little latitude there. Charge us $300. We’ll pay you $150, and save our insureds $150 in the process.”

And that was how it was done. And it’s perfectly legal.

I tell that story by way of analogy.

Now let’s dream a bit. Imagine for a moment you are a pharmaceutical company CEO. You produce drugs that help sick people be healthy. Trouble is, the great big US healthcare system in which you operate makes Rube Goldberg seem like Thomas Edison. And in the center of your part of it sit pharmacy benefit managers, PBMs.

As we saw in Part One, the PBM industry has evolved in a rather chaotic way since Pharmaceutical Card System, Inc., invented the plastic benefit card in 1968. Over the intervening years, pharmacies and PBMs have developed into sometimes incestuous relationships. Today, three PBMs, Express Scripts, CVS Caremark and Optum RX, control 78% of the market. They wield tremendous power in drug pricing in a system designed to be opaque.

Essentially, the PBM’s job is to negotiate with pharmacies and drug companies, like yours, on behalf of their insurer and health plan clients. They create formularies, negotiate prices down (you give them a big discount in return for your drug being listed in their formulary), return some of the savings, called rebates,  to the clients (nobody really knows how much), and keep some for themselves. Seems simple, right? Well, it’s not. It’s infinitely more complicated and complex. And because only a very few actually understand PBMs, they remind me of the shenanigans in The Wizard Of Oz. However, it is that way only because we have allowed it to happen over the last four decades.

But back to you, Here’s your issue as a drug company CEO: You know, regardless of what price you set for your super-duper drug, you’re going to have to give a lot of it back as a discount to the PBM so it can give rebates to its clients. What’s a busy CEO to do?

Well, one answer is to set the price, the list price, so high that you’ll be able to provide a generous discount and still make what your finance folks say you must have for a profit. Just like in my analogy from above.

In a weird sort of way, this works most of the time for patients, but only if they have health insurance. What happens if they don’t? This is where things get sticky. Uninsured people get stuck paying the full list price, the one you inflated in order to provide the discount that allows you to make a profit and PBMs to (kind of) save money for their customers. This has been especially difficult for some uninsured Type 1 diabetics, who, as we have written previously (here and here), have had great difficulty paying for the insulin they need to take every day ─  just to stay alive.

Many employers have had enough of this. According to the National Business Group on Health, 75% of surveyed employers believe the rebate system does not serve to lower prices for employees, and 91% believe an alternative, more simple approach is required. Then there is CMS’s Alex Azar, of Ely Lilly fame, who wants you to price your drugs like Europeans do, which is a water fall lower than prices in the US. And let us not forget the current occupant of 1600 Pennsylvania Avenue, who, as yet unable to fulfill a campaign promise about a wall, has an outside chance of fulfilling one about drug prices.

Neither the healthcare industry, nor the US Chamber of Commerce like any of this. I imagine it might also be a bit awkward for quite a few US legislators who have been significant beneficiaries of the healthcare industry’s largesse, largess of the campaign contribution variety.

Regardless, I’m an optimist, and I keep hoping that in some way the wizard behind the healthcare curtain will go ‘poof,’ and be gone. Silly me.

 

 

The Wizard Behind The Curtain – Part One

February 1st, 2019 by Tom Lynch

Suddenly, everybody’s out to get Pharmacy Benefit Managers, or PBMs. CMS, state legislatures, state Medicaid officials, a boatload of experts and even Donald Trump, who appears to actually and sincerely believe PBMs have created a rigged system.

The issue, what you and I pay for medicine, is getting a lot of ink and airtime. As well it should. Drug prices in the US are nearly twice as high as other developed nations. How did it come to this, and are PBMs a big part of the problem or are they a modern Horatius at the Bridge holding back an invading army of even steeper costs?

The PBM industry was born in the late 1960s when Pharmaceutical Card System, Inc., (PCS) invented the plastic benefit card. By the mid-1970s, PCS was serving as a fiscal intermediary by adjudicating drug claims. In other words, it was a prescription Third Party Administrator (TPA). By working for insurers and health plans, PCS (later AdvancePCS) and others figured out that they could leverage the buying power of their clients to negotiate lower drug prices.  And until around 1992, that’s they did. During that approximately 20 year period, PBMs saved insurers, health plans and consumers money by driving physicians and patients to use lower cost generic drugs. This was a valuable service for all.

In 1992, however,  PBMs began to change their focus. As noted by the Wall Street Journal in August, 2002, from 1992 through 2002, PBMs had “quietly moved” into marketing expensive brand name drugs. Since then, two major problems have emerged.

First, there is an incestuous relationship between PBMs and pharmacy companies. This occurred over three periods.

From 1968 through 1994, pharmaceutical companies acquired PBMs. For example, in 1994 Eli Lilly bought PCS for $4 billion and SmithKline Beecham bought Diversified Pharmaceutical Services (from insurer UnitedHealth) for $2.3 billion. But the FTC saw anti trust implications these deals created and ordered the acquisitions to stop and the pharmaceutical firms to divest the PBMs.

So, Eli Lilly sold PCS Health Systems to Rite Aid for $1.5 billion,  SmithKline Beecham sold Diversified Pharmaceutical Services to Express Scripts for $700 million and Merck spun off Medco Health Solutions, the PBM for 68 million Americans at the time.

The third PBM evolutionary period, the one we’re now living in, has seen mergers between PBMs and PBMs with pharmacy chains. In 2000, Advance Paradigm bought PCS for $1 billion, and changed the name to AdvancePCS; in 2003 Caremark bought AdvancePCS for $5.6 billion; and in 2007, CVS bought Caremark for $26.5 billion. Similar long and winding roads have resulted in three PBMs, CVS Caremark, Express Scripts and OptumRX cornering 78% of the nation’s PBM business, serving 266 million Americans. Revenue for these three firms in 2017 was about $300 billion. And these costs are growing at an accelerated pace. According to the American Academy of Actuaries:

In some years, prescription drug spending growth has far exceeded the growth in other medical spending, while in others it has fallen below other medical spending growth. Over the next decade, however, the Centers for Medicare and Medicaid Services (CMS) projects that spending for retail prescription drugs will be the fastest growth health category and will consistently outpace that of other health spending.

Which brings us to the second big problem. The one everyone’s talking about.

More about that next week. After the Patriots win Super Bowl LIII!

Low Wage Workers Pay More For Health Care Than High Wage Workers

January 21st, 2019 by Tom Lynch

Anyone who can rub two brain cells together knows America spends more, much more, on health care than any other developed nation, as this chart from the Organization for Economic and Cooperative Development  (OECD) shows.

Also well established is the sad fact that in terms of health care outcomes our brethren in the OECD – Canada, England, Germany and France, for example – fare better than we.

Now, recent data published by the Bureau of Labor Statistics show lower wage workers pay more for health insurance than higher wage workers in employer provided plans.

What this means is: The employee portion of the monthly premium for family coverage paid by the lowest 10% of earners is $612, while the monthly premium for the highest 10% is $488. The lowest 10% of earners pay 25% more than the highest 10%. Similar results for single coverage.  Look at the light blue and light green bars in each of the strata in the chart. The more you make, the less you pay.

This is wacky. And terribly unfair. But wait, there’s more.

For every year in the 21st century, this has been getting worse.

From 2000 through 2018, health insurance costs for a single person in an employer-provided health plan rose 179%; family coverage rose 204%. During this same period, the Consumer Price Index was up 49%, while earnings for hourly employees grew by 48%. So, essentially, workers’ pay matched inflation, meaning real wages, wages adjusted for inflation, did not move as health care costs continued their rocket ride to the moon.

I keep thinking this cannot continue. I keep thinking Herb Stein was right: If something cannot go on forever, it will stop. And I keep being proven wrong. The fact is, up until the mid-1980s, our health care system was like a typical family home with its two bedrooms, a bath and a half and a nice little two-car garage. Today, it seems like the 1,000-room, maze-like Windsor castle where you need a map and a guide to find your way around. Vested interests litter the landscape, and any change gores somebody’s ox.

How can we possibly stop this runaway train? Many placed hope in the Affordable Care Act, but look what’s happened to that. The new generation of Democrats yearns for “Medicare For All,” but has yet to figure out how to pay for it. Others suggest “Medicaid For All,” but Medicaid is a state-based system, and every state has its own version. I’d love to see a single payer system, but, looking at the lunacy behind our current government shutdown, can you envision that cresting over the horizon, given all the work and bi-partisanship it would take? When I look at the health care horizon, I see the Four Horsemen of the Apocalypse coming over the rise.

Certainly, there are pockets of innovation and excellence around the nation, but we have no national, systemic approach to fix to the problem of extraordinary high costs, and it’s hard to imagine this congress, or any congress, doing anything about that. At more than $8 billion dollars, the health care industry spends more on lobbying than any other industry, and that’s not about to change, once again proving Mark Twain right: We have the best government money can buy.

I believe the work done in those “pockets of excellence” will gradually lead to improved health for Americans who can afford to pay for it. It’s the “can afford to pay for it” part that sickens me.

A Message To Our Readers

January 19th, 2019 by Tom Lynch

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Due to a technical error (mine!), yesterday’s blog post was transmitted incorrectly. The post was meant to detail how lower wage workers pay more for employer provided health insurance than higher wage workers. We will publish the corrected post on Monday.

Thanks to the many readers who alerted us to the problem.

Tom Lynch

Bulletin: Dog Catches Bus. Appears Confused.

December 18th, 2018 by Tom Lynch

 

After Sen. John McCain’s dramatic “no” vote in July 2017 that kept the ACA alive, Newsweek found at least 70 Republican-led attempts to repeal, modify or otherwise curb the Affordable Care Act since its inception as law on March 23, 2010. All of those attempts failed. But what the Republican-controlled congress couldn’t do in 70 attempts over eight years, a single federal judge from Texas my have done with the stroke of his pen.

In February, a Texas-led coalition of 20 states sued the federal government to end the health care law in its entirety, arguing that after Congress in December 2017 gutted one of its major provisions, a financial penalty for not having health insurance known as the “individual mandate,” the rest of the law was unconstitutional. Last Friday, Fort Worth-based U.S. District Judge Reed O’Connor sided with Texas, ruling that without the individual mandate the entire Affordable Care Act is unconstitutional.

In a not unprecedented, but certainly rare, move earlier in the year the justice Department had announced it would not defend the suit, prompting a counter-coalition of states, led by California, to step in to argue the case.

There will be appeals – first to the full District Court and, if that fails, to the Supreme Court. Until those appeals are exhausted, the law will remain in place. Judge O’Connor’s ruling stands a pretty good chance of being overturned by the higher courts. According to the Texas Tribune, Timothy Jost, an emeritus professor at Washington and Lee University who has studied Obamacare and its legal battles extensively, called Friday’s ruling “an ideological opinion” that is “unmoored in law.” Regardless, democrats, who retook the House last month by making the threat that republicans were set to throw the ACA’s pre-existing condition protections, as well as a number of other Obamacare provisions voters love, on the dust heap of history, are now even more ammo’d-up for 2020.

And what about those bus-catching republicans, who have, at least for the moment, been given the thing they’ve wanted most for the last eight years? Well, to put it as kindly as these circumstances allow, they appear to be clueless. Republican leaders, although having the last eight years to come up with one, have yet to advance even the tiniest plan for what to do if the ruling is upheld. About the most we can say for them is this:

They’re women and men,
who want to go back to 2010
and start the health care war all over again.

President Trump called it “a great ruling” and tweeted “Congress must pass a STRONG law that provides GREAT healthcare and protects pre-existing conditions. Mitch and Nancy, get it done!” Right.

As of this writing, however, Trump’s troops do not appear eager to follow their Commander in Chief as he, unarmed, storms the health care barricades. Meanwhile, all the ACA-haters seem to be able to do is gloat. This whole thing is getting better than kicking back on a Saturday afternoon with a bag of popcorn watching the adventures of the Keystone Cops.

Let us pray sanity prevails.

 

Check out the holiday Health Wonk Review & other news of note

December 14th, 2018 by Julie Ferguson

There’s a new December Health Wonk Review posted by Peggy Salvatore at Health System Ed Blog – check out Have a Holly, Jolly Health Wonk Holiday from Health Wonk Review. There are entries from many of the regulars – catch up on the latest & greatest.

 

 

 

 

In other news that has caught our attention

Chemical Safety Board Asks for Combustible Dust Input – The Chemical Safety Board continues to investigate five combustible dust incidents. A comprehensive combustible dust standard still does not exists, and the Chemical Safety Board (CSB) is seeking further input to put one in place. The federal agency has extended its deadline for comment to December 31 from companies, regulators, inspectors, safety training providers, researchers, unions, and the workers of dust-producing operations.

A fire, a frantic search and the loss of one of Worcester’s bravest: How the scene unfolded in the death of Firefighter Christopher Roy. Here at Lynch Ryan, we have a connection to the Worcester MA community and know that December has proven to be a cruel month for the Worcester Fire Department. We recently lost a firefighter in the same month that saw 6 deaths in the Cold Storage warehouse fire some 19 years ago, and another fatality in 2011. We salute brave and dedicated firefighters everywhere for putting their lives on the line.

And in this holiday season, we are mindful of all the workers who won’t be celebrating with their families because they died on the job. All of us in the workers’ compensation industry should remember that at the heart of what we do, it is about keeping workers safe on the job. We thank Jordan Barab for continuing on with his Weekly Toll posts, a sad ongoing commemoration of people who die on the job – a reminder that we need to continue to work to greater safety. See his most recent posts, Weekly Toll: Three Weeks of Death on the Job  and Weekly Toll: Human Statistics Who Won’t Be Coming Home.

Missed the 2018 National Workers’ Compensation & Disability Conference? In addition to recaps at Risk & Insurance, the event sponsor, some other places we turn to for updates are Joe Paduda’s blog and Safety National’s Conference Chronicles.

Ohio Business Owner Sentenced to Prison for $425K Workers’ Comp Fraud  It’s not all that often that we see jail time for workers’ comp fraus, but the owner of Employers Choice Plus LLC payroll services company convicted in June on wire fraud and money laundering charges after BWC and IRS investigators discovered a scheme he concocted to short BWC on the insurance premiums he received from employers and pocket the difference.

How Exoskeletons Can Solve Safety and Productivity Issues – Encroaching automation. The skills gap. The opioid epidemic. These are real problems the first legitimate power-amplifying exoskeleton could take on when it’s released in a little over a year.

Temporary Workers and Lockout/Tagout—Guidance for Employers

How Climate Change Is Challenging American Health Care

Shame, Scandal Plague Healthcare Providers In 2018

And in the workplace of the future department:

Will Amazon Make Human Workers Obsolete?

AI in the workplace: Everything you need to know – How artificial intelligence will change the world of work, for better and for worse.

Robots in the workplace – As new technologies bring robots side by side with human workers, what are the safety implications?

Meet AnyMal. This robot recently autonomously performed various inspection tasks of the world’s largest offshore converter platforms in the North Sea in a one-week pilot installation, making it the world’s first autonomous offshore robot.

What Price Life? Part Two

December 12th, 2018 by Tom Lynch

Part Two

“Insulin is my gift to mankind” – Frederick Banting

In Part One, we noted the critical need for daily insulin injections to keep Type 1 Diabetics (T1Ds) alive. We described how Frederick Banting’s team of himself, Charles Best and James Collip recovered and purified insulin from the fetal pancreases of cows and pigs in 1922, how they successfully tested it on humans, how Banting won the Nobel Prize the following year for his discovery, how the team sold the patent for the discovery to the University of Toronto for $3.00 and how they and the University agreed to license the manufacturing rights to pharmaceutical companies royalty-free, because, in Banting’s words, “Insulin is my gift to mankind.” The team and the university wanted to incentivise drug companies to improve on the Banting team’s discovery, so the University and Banting agreed to allow the companies to improve Banting’s formulation if they could and patent any new discoveries that arose. Their hope was that drug companies would share their vision of making it possible for T1Ds to live high-quality lives and to keep insulin prices low to help them do it.

Immediately after the sale of the patent to the University of Toronto, the University licensed the manufacturing rights for insulin to Eli Lilly and Company, located in Indianapolis, Indianna, and Nordisk Insulin laboratorium in Copenhagen. Meanwhile, a few kilometers away in Copenhagen, Novo Terapeutisk Laboratorium succeeded in producing a stable liquid insulin product which it called Insulin Novo. Decades later, in 1989, these two companies would merge to become Novo Nordisk.

In the beginning, the pharmaceutical companies had the best of intentions. After all, they were manufacturing and marketing the world’s first “life-saving” drug.

Over time, the “best intentions” became the quarterly bottom line and shareholder value. The emphasis was now on next generation patents, which would stifle competition and prevent the emergence of insulin generic drugs. To this day, there isn’t one.

It is not an exaggeration to say insulin made Eli Lilly and Company and Novo Nordisk two of the top pharmaceutical companies in the world. It also hasn’t hurt the bottom line of Sanofi, the company that rounds out the insulin producing triumvirate and is the world’s fifth largest pharma by sales.

In the last 20 years, these insulin producing companies have become swept up in the craziness of U.S. health care, where prices are on a rocket ride to the moon. During that time, the list price of insulin has increased more than 700%. Of course, T1Ds who have employer sponsored health insurance don’t pay list price. The price they pay, which is much lower, is  negotiated by their insurance company or Pharmacy Benefit Manager. This also applies to T1Ds who have secured insurance either through the expansion of the Affordable Care Act or some other means. They find their insulin relatively affordable, unless they have a prescription deductible which forces them to pay the full amount for insulin until they reach the deductible total. Finally, diabetics on Part D must pay 45% of list price when they fall into the infamous “donut hole.”

But children without insurance are in a very bad place, and there are a lot of them – 3.9 million in 2017 under the age of 19 (300 thousand more than 2016).

This situation is worse, twice as worse, in states that have not expanded Medicaid through the Affordable Care Act.

Kids with Type 1 Diabetes make up about .05%, of the uninsured group. That’s 195,000 children. And then there are the young, T1D adults who can no longer be on their parents insurance plan, because they are over the age of 26. Recently, we have learned of  T1Ds who have been forced to ration their insulin. This has resulted in tragic deaths. Parents and guardians have begun to protest at pharmaceutical company gates, some carrying the ashes of their dead children. Think about that.

So, here’s a question: Should anyone in the United States who requires a daily drug just to stay alive be forced to come up with the money to pay for it? Or, should that be a government-sponsored, health care right, as in the Declaration Of Independence’s “self-evident…unalienable right…to life.”

While you ponder that, I’ll leave you with this. Banting, Best and Collip would be tremendously gratified that their “gift to mankind” has enabled millions upon millions of Type 1 diabetics to lead productive, fulfilling lives. But they would be horrified that the drug’s price is now exacting a human price of obscene proportions.

 

 

What Price Life?

November 29th, 2018 by Tom Lynch

Part One

“Insulin is my gift to mankind” – Frederick Banting

A Quick Quiz

Question 1: Name a chronic disease requiring medication, which, if not taken every day, guarantees death within two weeks.
Answer: Type 1 Diabetes.

Question 2: Name the medication.
Answer: Insulin.

Question 3: What is the monthly cost of insulin for a Type 1 diabetic?
Answer: As we shall see, that depends.

Question 4: If Type 1 diabetics cannot afford the cost of insulin, without which they will surely die, what should they do?
Answer: This is happening at this moment, and people are dying.  In these two blog posts we’ll examine why and what can be done about it. But we need to first posit some truths about diabetes, and then describe how, in 1922, Canadian doctor Frederick Banting made the ground-breaking discovery that allowed Type 1 diabetics, for the first time in history, to live.

Ten Fast Facts

  1. Insulin is a hormone made by the pancreas that allows the body to use sugar (glucose) from carbohydrates in the food we eat for energy or to store glucose for future use. Insulin helps keeps blood sugar levels from getting too high (hyperglycemia) or too low (hypoglycemia). Type 1 diabetics, T1Ds, can no longer produce insulin. They have none of it. Although older adults can also contract Type 1 diabetes, it usually strikes children and young adults. Without insulin, whether old or young, they die.
  2. There are about 1.3 million T1Ds in the U.S. They comprise one half of one percent of the population. Currently, there is no cure for any of them. Without insulin, they will die.
  3. There are about 29 million Type 2 diabetics. T2Ds still make some insulin. In most, lifestyle changes will improve their health, sometimes to the point where they will no longer require insulin or any other medical prescriptions. Some will become insulin-dependent, and without it, they face life-changing complications.
  4. Diabetic Retinopathy is the leading cause of blindness.
  5. Diabetes is the leading cause of non-traumatic amputation.
  6. Diabetes is a leading cause of heart attack and stroke.
  7. Diabetes is the leading cause of kidney failure.
  8. Complications from diabetes sometimes cause workplace injuries and often exacerbate the severity and length of recovery.
  9. In 2017, the nation’s total direct medical costs due to diabetes were $237 billion. Average medical expenses for diabetics were 2.3 times higher than for non-diabetics. The extent to which diabetes added to workers’ compensation medical costs is unknown.
  10. Based on information found on death certificates, diabetes was the 7th leading cause of death in the United States in 2015, with 79,535 death certificates listing it as the underlying cause of death, and 252,806 listing diabetes as an underlying or contributing cause of death. However, diabetes is underreported as a cause of death; studies have found that only about 35% to 40% of people with diabetes who died had diabetes listed anywhere on the death certificate and only 10% to 15% had it listed as the underlying cause of death. An example of best practice would be, “Death caused by infection contracted from hemodialysis due to kidney failure, a complication of the patient’s diabetes.”

Banting and Insulin

Image result for photo of frederick banting

Frederick Banting is perhaps Canada’s greatest hero. Born in 1891, he graduated medical school with a surgical degree in 1915 and found himself in a French trench by the end of 1917. In December of that year, he was wounded during the Battle of Cambrai, the first great tank battle in history. He remained on the battlefield for 16 hours tending to other wounded soldiers until he had to be ordered to the rear to have his own wounds treated. For this action he won the British Military Cross, akin to America’s Silver Star. After returning to Canada, he continued his studies and, in 1920, secured a part time teaching post at Western Ontario University. While there, he began studying insulin Why? Serendipity. Someone had asked him to give a talk on the workings of the pancreas.

Banting became interested – and then obsessed – with trying to come up with a way to get insulin to people who couldn’t make any of their own. In November 1921, he hit on the idea of extracting insulin from fetal pancreases of cows and pigs. He discussed the approach with J. R. R. MacLeod, Professor of Physiology at the University of Toronto. MacLeod thought Banting’s idea was doomed to failure, but he allowed him to use his lab facilities while he was on a golfing holiday in Scotland. He also loaned him two assistants, Dr. Charles Best and biochemist James Collip. Collip devised a method to purify the insulin Banting and Best obtained from the fetal pancreases.

To MacLeod’s surprise, Banting’s procedure worked, and in 1922 Banting and Best successfully treated the daughter of US Secretary of State Charles Evans Hughes.

In 1923, one year later, Banting, at the age of 32, won the Nobel Prize, which, to his disgust, he had to share with MacLeod. To this day, Frederick Banting is the youngest person ever to win the Prize in Physiology or Medicine.

His discovery could have made Banting mind-numbingly rich, but he would have none of that. Along with Best and Collip, Banting patented his method and then the three of them sold the patent to the University of Toronto for the princely sum of $3.00. When asked why he didn’t cash in on his discovery, Banting said, “Insulin is my gift to mankind.” With Banting’s blessing, the University licensed insulin’s manufacturing to drug companies, royalty free. If drug companies didn’t have to pay royalties, Banting thought they would keep the price of insulin low.

And they did. For decades.

But patents expire, and capitalism being what it is, people get greedy, and greed is why we have no generic, low-cost insulin today and why, over the past 20 years, insulin prices have risen anywhere from 800% to 1,157%, depending on the variety and brand. It’s why, lacking health insurance, some Type 1 diabetics have recently been driven to ration their precious insulin. Some of them have died.

More about all that in Part Two.

 

 

 

Violence In The ER: A Big Problem Getting Worse

November 26th, 2018 by Tom Lynch

Men and women who yearn to follow in the footsteps of Hippocrates, Galen and Banting are taught many things in Med School, but there is no course called Violence In The ER, And What To Do When It Happens To You. 

Until recent times that hasn’t been much of an issue for the doctors and nurses who take care of us when we need critical care in a hurry. But in the 21st century, violence in the ER has become less the exception and more the rule.

In a 2018 American College of Emergency Physicians (ACEP) survey of 3,539 ER doctors, 47% reported being assaulted at work, 60% of those within the last year.

Why is this happening? According to ACEP, there are at least three problems with no easy solutions causing the sharp uptick in ER violence.

First, America has a tremendous shortage of psychiatric beds for people in profound mental stress. That means people in serious need of behavioral and mental health care can languish on a gurney in the ER for days, even weeks until a bed becomes available somewhere. Second, patients who’ve become addicted to opioids often show up in the ER demanding medication, and when they don’t get it things can get dicey in a hurry. Third, hospitals haven’t done enough to protect physicians and nurses from attacks by highly-stressed knife and (sometimes) gun wielding patients. Some hospitals have installed metal detectors at entrances, but the detectors and the labor required to screen incoming people can be pretty expensive, especially to a cash-strapped community hospital. Even with the metal detectors, many doctors in the ACEP study reported being kicked, punched, bitten and spit upon by deranged patients. This is a difficult issue for hospital risk managers to confront successfully.

We’ve known for many years that nurses and nursing aides are much more likely than other professionals to be victims of violence in the workplace. According to the US Bureau of Labor Statistics, “intentional injury’’ by another person rose nearly 50%, from 6.4 per 10,000 hospital workers in 2011 to 9.0 per 10,000 hospital workers in 2016, the most recent year of data. The rate across private industry is 1.7. OSHA has analyzed this and published Guidelines for dealing with it. But the ACEP survey is one of the first to shine a light on the stark potential for violent harm confronting Emergency Physicians.

One wonders if the threat of violence in the ER will dissuade med school graduates from specializing in Emergency Medicine. This would certainly be unfortunate, because a shortage already exists for rural ER physicians as documented in a June 2018 study published in the Annals of Emergency Medicine. At the time of the study, more than 27 percent of US rural  counties did not have emergency medicine clinicians and 41.4 percent of counties did not have any emergency physicians reimbursed by Medicare fee-for-service Part B, according to the study.

We’ll continue to follow this phenomenon and occasionally report on progress or lack of it in protecting these highly trained and dedicated life savers. For, now, consider this graphic from the aforementioned ACEP study.