Archive for the ‘health care’ Category

Andrew Cuomo Is Right: Send Him The Ventilators!

Friday, March 27th, 2020

If the state of New York were a country, it would have the highest rate of CoVid 19 cases per million inhabitants in the world. By far. As of 8:00 AM this morning, 27 March, New York clocked in with 38,987 cases, up more than 8,000 cases, or 27%, from two days ago. With 19.54 million people, New York’s rate of CoVid 19 cases is 1,995 per million inhabitants. The country with the highest rate is Switzerland with 1,387 cases per million inhabitants. But Switzerland only has 8.6 million people.

 

 

The populations of Spain, Italy and France are two to three times that of New York’s; Germany’s four times. So, New York would rank as a relatively small, but still respectably-sized, European country.

Looking at the dire predictions of most experts, Governor Andrew Cuomo believes New York is going to need 30,000 ventilators, and it’s going to need them about two weeks from now.

Donald Trump does not agree. He doesn’t see the need. At his daily… well, what would you call it? It’s certainly not a traditional press briefing. But, whatever you’d call it, yesterday he downplayed the need, and Dr. Deborah Birx, the White House Corona Virus Response Coordinator, whatever that means, sort of backed him up. Sort of. But we’ll get to that in just  a moment.

Last night, talking with Sean Hannity, who may be the sub rosa White House Coordinator, Trump said, “I have a feeling that a lot of the numbers that are being said in some areas are just bigger than they’re going to be. I don’t believe you need 40,000 or 30,000 ventilators. You go into major hospitals sometimes, and they’ll have two ventilators. And now, all of a sudden, they’re saying, ‘Can we order 30,000 ventilators?'”

“I have a feeling.” ” I don’t believe.” Think about that for a minute and ponder the implications.

But back to Dr. Birx, who is skilled at nuance. What did she say about Cuomo’s request for ventilators? She said she was told New York had enough ventilators “to meet current needs.” She said that, while New York City may have a shortage of ventilators at the moment, there are other parts of the state “that have lots of ventilators and other parts of New York state that don’t have any infections right now.”

Unpack what Dr. Birx said and you find she is careful to talk about what is needed right now. Cuomo is talking about what will be needed in two weeks when the proverbial fecal matter has hit the whirring instrument head on.

Right now New York has scrounged up about 15,000 ventilators, half the ventilators Cuomo and his experts say they’ll need in two weeks.

The White House Corona Virus Response Team has a choice here. It can either look at New York with a panoramic view, or continue to pretend they’re glimpsing an arrow as it whizzes past a crack in the door.

If you were making the ventilator decisions, which view would you want?

 

CoVid 19 And The Flu: Some Historical Perspective That Might Surprise You

Thursday, March 26th, 2020

Early in the morning of 4 March 1918, at Fort Riley, Kansas, Private Albert Gitchell reported for sick call at the Fort’s Hospital complaining of sore throat, fever and  a headache. By that noon, more than 100 other Fort Riley soldiers were at the hospital with similar symptoms. This was soon followed by similar outbreaks at other Army posts and prisons around America. Epidemiologists believe this to be the beginning of what came to be known as the Spanish Flu.

That March, 84,000 “Doughboys” shipped out for Europe, to be followed by another 118,000 in April. They brought the highly contagious flu with them. Soon, all of Europe and parts of Asia were infected. In June, Great Britain reported 31,000 cases (As I write this – 26 March – New York is reporting more than 30,000 cases of Covid 19). France and Germany suffered, too. Germany’s Crown Prince Rupprecht wrote on August 3. “Poor provisions, heavy losses, and the deepening influenza have deeply depressed the spirits of men in the III Infantry Division.” Soon, Russia, North Africa, India, China, Japan, the Philippines and even New Zealand would fall victim, as well.

The war ended on 11 November and the soldiers went home, bringing more of the disease with them. A second wave then hit America, much more devastating than the first. It infected 28% of the country’s population including my 5-year old Dad, who survived, thank you very much. It finally petered out at the end of 1919. As today, younger people seemed to combat the disease better than the aged.

From March through November, Americans did not know much about the Flu and its effect on the population. The Central Powers took great pains to censor bad news, trying to keep morale high. The first reports of the Flu came in May from Spain, a neutral country with uncensored media. Hence, it became the Spanish Flu. But when the war ended the ropes came off and the world knew it was in the grips of what would become the worst pandemic in history, rivaled only by the Bubonic Plague, caused by Yersinia Pestis, the black rat, in the mid-14th century. That plague killed more than two million people in England alone, 40% to 50% of the population, and the population would not recover to its former level until the early 1800s.

When Americans finally learned what the Spanish Flu was doing to them what happened?

Well, first of all, there was no vaccine and no curative treatment. Sound familiar? Second, because of not wanting to spread bad news, the government delayed mobilizing fully to combat a different kind of enemy. Sound familiar? When it did, what did it do? As now, with CoVid 19, the burden fell mostly on Governors, Mayors and local health officials. Because the Flu was so widespread, affecting the entire country at once, most states and cities were on their own. Many made tragic mistakes, as many are doing now. Actions in Philadelphia and St. Louis, MO, provide two 1919 examples.

As cases mounted, Philadelphia went forward with a Liberty Loan parade attended by tens of thousands, shoulder to shoulder. The disease exploded exponentially. In just 10 days, over 1,000 Philadelphians were dead, with another 200,000 sick. Only then did the city close saloons and theaters. By March, 1919, over 15,000 Philadelphians had died.

In St. Louis, the mayor ordered schools and movie theatres closed and banned public gatherings. The St. Louis mortality rate was one-eighth that of Philadelphia’s.

On the whole, Americans fought the Spanish Flu the same way we’re fighting CoVid 19 – social distancing, wearing masks and gloves, washing hands and staying at home. They had no cure; neither do we. Eventually, in the 1940s, the first flu vaccine was created. Now, sixty years later, only 40% of Americans take the trouble to get vaccinated yearly for the flu, 30,000 to 40,000 die annually and 200,000 are hospitalized.

Make no mistake. CoVid 19 is not like the flu – of today. But it is very much like the Spanish Flu of 1918 and 1919.

We will have a vaccine to combat CoVid 19. Right now we’re in the middle of a traffic jam of attempts, but it will happen. I only hope for two things. First, that the Corona Virus doesn’t mutate annually, like the flu. Second, that all Americans wake up and get vaccinated for both this virus as soon as they can and, finally, for the flu.

CoVid 19 Upate

Tuesday, March 17th, 2020

Nuggets arriving over the transom.

Blood Supply

The American Red Cross is facing a serious blood shortage RIGHT NOW.

“We need people to start turning out in force to give blood,” Dr. Peter Marks, director of the FDA’s biologics evaluation and research, said in a statement. “We need people to prevent the blood supply from getting depleted. We need it not to get to the point that surgeries are having to get cancelled,” Marks said. “That’s something we absolutely do not want to have happen. To ensure an adequate blood supply we need people to come out and donate blood.”

Although hospitals around the country are cancelling elective surgeries, they cannot cancel emergency surgeries. A 2018 study concluded the Emergency-To-Elective Surgery Ratio to be 9.4 in the U.S., 5.5 in the E.U., but a whopping 62.6 in sub-Saharen Africa (not a lot of elective surgery going on there). Emergency surgeries still have to happen. So, what’s the beleaguered Red Cross to do? In this time of CoVid 19, it has quite the dillema. Federal and state governments tell us to stay home as much as possible, but the Red Cross, which faces an emergency every eight minutes, depends on people going to one of their centers to donate blood, which, given the virus scare, is something many are finding hard to do.

Information – Where To Get It

Everywhere you look (including this blog), people are passing on CoVid 19 updates. It can all be a bit of a mish-mash. So, at the risk of compounding the problem, I’d like to suggest looking at the website of the European Centre for Disease Prevention and Control (ECDC). It is superbly organized and helpful. Its staff publishes Situation Updates every day, both for Europe and the world. The main reason to spend some time with the ECDC is to get a better idea of what is likely heading our way. Europe is about two weeks ahead of us for CoVid 19 communal spreading, and the ECDC’s charts are well-done, enlightening and scary. Compare the Situation Updates in Europe to the CDC’s here and here in the U.S.

And In The World Of Workers’ Compensation

The state of Washington was the first U.S. CoVid 19 hot spot. We noted yesterday the plight of a 70-year-old Washington ER doctor who was in critical condition after contracting the disease. That certainly qualifies for workers’ compensation benefits. But what about clinicians, doctors and nurses who, although asymptomatic, are forced to quarantine themselves for two weeks following exposure? It’s one thing if their employers continue to pay them while quarantined, but what if they don’t? And what about the health care charges incurred during quarantine? Who pays?

In a move that could start a trend, Governor Jay Inslee yesterday said any Washington health care workers forced to quarantine themselves following exposure would qualify for workers’ compensation benefits. Will this propel health care institutions to discontinue paying clinicians under quarantine? Regardless, workers’ compensation covering all the health care charges is a big deal.

Like a red rope in the snow, we will follow this story to see whether other states follow Inslee’s lead.

And now to once more assume the position of the CoVid 19 shut-in and watch the Dow Jones bounce around like a bee bee in a boxcar.

Stay safe.

 

 

CoVid 19 Update

Monday, March 16th, 2020

Physicians on the front lines of CoVid 19 defence are getting sick. The American College of Emergency Physicians reports two ER doctors are in critical condition after contracting the disease, one in his 40s in Washington State, the other a 70-year-old doctor in New Jersey.

Which brings us to something nobody seems to be talking about, nobody, that is, except the inestimable Jennifer Christian, about whom I wrote last week. In today’s Work Fitness and Disability Roundtable, Jennifer asks about the consequences to elderly doctors and nurses when the federal government and all the states tell the elderly to stay home. What are the implications?

From today’s Roundtable:

The 2018 Census of Licensed Physicians in the US ( https://www.fsmb.org/siteassets/advocacy/publications/2018census.pdf ) by the Federal of State Medical Boards found 985,026 physicians now licensed to practice medicine the US (which doesn’t necessarily mean they are in active practice), with 30.3% of them 60+ years old in 2018, compared to 25.2% in 2010.   If we use the 2019 State Physician Workforce Data Report ( https://store.aamc.org/2019-state-physician-workforce-data-report.html ) from the Amer Assoc of Medical Colleges which identifies physicians in ACTIVE PRACTICE based on the 2018 AMA Physician Masterfile, there are currently 908,760 physicians in active practice, and of those 32.1% are at least 60 years of age.   Sending them all home means benching 291,711 doctors.

Alright, let’s all agree we’re not going to tell nearly 300,000 physicians to stay home during the worst healthcare crisis of the last century. So, how do we protect them?

The first line of defence for ER physicians and nurses is personal protective equipment (PPE). That means appropriate face masks, gowns, gloves, soap and the like. Trouble is, the U.S. doesn’t have nearly enough PPE to go around if our coming experience resembles that of Italy or Wuhan. Think about that for a minute.

The only way to reduce the coming harm to elderly clinicians is to reduce the cases – flatten the curve. This presents each one of us with a choice. Either we do everything possible to avoid the disease – social distancing, staying home, washing hands, etc. – or, we engage in communal irresponsibility by treating all the warnings as mere suggestions, sort of the way we treat highway speed limits.

That type of behavior was very much in evidence over the weekend, from St. Patrick’s Day get togethers all over the country to Bourbon Street parties in New Orleans. Then, of course, there was the horrendoma at O’Hare and twelve other airports yesterday, as thousands of people tried to get back to  the USA from overseas and had to stand for hours elbow to elbow waiting to get screened for a virus many of them were probably spreading  during the communal scrum. Will somebody please tell me why our federal government continues to do things that have all the competence and well-thoughtoutedness of a Keystone Cops car chase?

All clinicians, expecially the heroic elderly ones now on the front lines, deserve our full-throttled disease avoidance engagement. Otherwise, we’re going to wake up a couple of weeks from now only to discover, as the bodies pile up, that what we did was way too little, way too late.

Have a nice day.

 

A Warning From One Who Knows

Thursday, March 12th, 2020

CoVid 19 appears to have begun in China. It then made its way around the world, and is now an “official global pandemic.” Last night, Donald Trump, in television primetime, addressed the nation and described what he and his administration are doing and plan to do to mitigate the pandemic’s effects in America. I won’t get into what I thought about his address, except to say that until the Fed intervened two hours ago, the stock market was down 9% and was on pace to have its sixth-worst one-day decline in history. So much for Wall Street’s response.

This morning, Trump, sitting in the Oval Office with Ireland’s Prime Minister, Leo Valadkar, answered questions from the press. He repeatedly made the point that things in America are ever so much better than in Europe, which he seemed to blame for our current pandemic difficulties. We have the “best doctors in the world” and all the resources needed to defeat the oncoming enemy. More than once, he said, “We’ve only had 32 deaths.” He opined in that certitudinous way of his that the virus will go away, maybe in a month or two, and urged everyone to “keep separation.”

I mention this by way of introducing the longest post WorkersCompInsider has ever published, about 2,400 words. And it’s all Dr. Jennifer Christian’s fault.

Jennifer, as many of you may know, is the Moderator of WFDRoundtable, an intelligent, illuminating and educational group chat site for clinicians, academics, workers’ compensation professionals, and anyone else who might be interested in learning what the medical profession, in general, is doing and thinking about sick and injured people. I wrote glowingly about Jennifer and her work in 2014. Might be worth a revisit.

This morning’s Roundtable arrived with Jennifer introducing a Facebook post by Dr. Daniele Macchini, from the Humanitas Gavazzeni hospital in Bergamo, Italy (northeast of Milan). Dr. Macchini is at the center of Italy’s CoVid 19 storm. He is smack dab in the middle of it, and what he’s seen isn’t pretty. He and his colleagues in northern Italy have been through a lot in the last couple of weeks, and what he’s written should be read by every American. it is a picture of what can, and very likely will, happen here, despite our President’s protestations to the contrary.

This is Dr. Macchini’s story. It’s been Google-Translated from Italian.

In one of the constant emails that I receive from my health department more than daily now these days, there was also a paragraph entitled “being sociably responsible”, which made some recommendations that I support. After thinking for a long time if and what to write about what is happening to us, I felt that silence was not at all responsible. I will therefore try to convey to people “not involved in the work” and more distant from our reality, what we are experiencing in Bergamo during these pandemic days from Covid-19.

I understand the need not to panic. I also understand the economic damage and I am also worried about that. After the epidemic, the tragedy will start again. However, apart from the fact that we are literally also devastating our National Health Service from an economic point of view, I allow myself to raise the importance of the health damage that is likely throughout the country and I find it nothing short of “chilling” for example that a red zone already requested by the region has not yet been established for the municipalities of Alzano Lombardo and Nembro (I would like to clarify that this is pure personal opinion).

I myself looked with some amazement at the reorganizations of the entire hospital in the previous week, when our current enemy was still in the shadows: the wards slowly “emptied”, the elective activities interrupted, the intensive therapies freed to create as many beds as possible. Containers arriving in front of the emergency room to create diversified routes and avoid any infections. All this rapid transformation brought into the corridors of the hospital an atmosphere of surreal silence and emptiness that we still did not understand, waiting for a war that was yet to begin and that many (including me) were not so sure would never come with such ferocity . (All this was done in silence and without publicity.)

I still remember my night watch a week ago that passed anxiously as I waited for a call from the microbiology unit. I was waiting for the outcome of a swab on the first suspect patient in our hospital, thinking about what consequences it would have for us and the clinic. If I think about it, my agitation for one possible case seems almost ridiculous and unjustified, now that I have seen what is happening.

Well, the situation is now nothing short of dramatic. No other words come to mind. The war has literally exploded and the battles are uninterrupted day and night. One after the other the unfortunate poor people come to the emergency room. What they have is nothing like the complications of a flu. Let’s stop saying it’s a bad flu. In these 2 years I have learned that the people of Bergamo do not come to the emergency room without cause. They did well this time too. They followed all the indications given: a week or ten days at home with a fever without going out and risking contagion, but now they can’t take it anymore. They can get enough breath, they need oxygen.

Drug therapies for this virus are few. The course mainly depends on our organism. We can only support it when it can’t take it anymore. It is mainly hoped that our body will eradicate the virus on its own, let’s face it. Antiviral therapies are experimental on this virus and we learn its behavior day after day. Staying at home until the symptoms worsen does not change the prognosis of the disease.

Now, however, that need for beds in all its drama has arrived. One after another, the departments that had been emptied are filling up at an impressive rate. The display boards with the names of the sick, of different colors depending on the operating unit they belong to, are now all red and instead of the surgical operation there is the diagnosis, which is always the same cursed: bilateral interstitial pneumonia.

Now, tell me which flu virus causes such a rapid tragedy. Because that’s the difference (now I’m going down a bit in the technical field): in classical flu, apart from infecting much less of the population over several months, cases can be complicated less frequently, only when the VIRUS destroying the protective barriers of the our respiratory tract allowing BACTERIA normally resident in the upper tract to invade the bronchi and lungs, causing more serious cases. Covid 19 is mild in many young people, but in many elderly people (and not only) it causes a real Sudden Acute Respiratory Syndrome because it arrives directly in the alveoli of the lungs and infects them making them unable to perform their function.

Sorry, but to me as a doctor it shouldn’t reassure you that the most serious are mainly elderly people with other pathologies. The elderly population is the most represented in our country and it is difficult to find someone who, above 65 years of age, does not take at least the tablet for pressure or diabetes. I also assure you that when you see young people who end up in intubated intensive care, pronated or worse in ECMO (a machine for the worst cases, which extracts the blood, re-oxygenates it and returns it to the body, waiting for the organism, hopefully, heal its lungs), any comfort you might take from being young passes then and there.

And while there are still people on social networks who pride themselves on not being afraid by ignoring the indications, protesting that their normal lifestyle habits are “temporarily” in crisis, the epidemiological disaster is taking place. And there are no more surgeons, urologists, orthopedists. We are only doctors who suddenly become part of a single team to face this tsunami that has overwhelmed us. The cases multiply, we arrive at the rate of 15-20 hospitalizations a day all for the same reason. The results of the swabs now come one after the other: positive, positive, positive. Suddenly the emergency room is collapsing.

Emergency provisions are issued: help is needed in the emergency room. A quick meeting to learn how the first aid management software works and a few minutes later they are already downstairs, next to the warriors on the war front. The screen of the PC with the reasons for the access is always the same: fever and respiratory difficulty, fever and cough, respiratory insufficiency etc … Exams, radiology always with the same sentence: bilateral interstitial pneumonia, bilateral interstitial pneumonia, bilateral interstitial pneumonia. All to be hospitalized. Someone already to intubate and go to intensive care. For others it is too late …

Intensive care becomes saturated, and where intensive care ends, more are created. Each ventilator becomes like gold: those of the operating rooms that have now suspended their non-urgent activity become places for intensive care that did not exist before. I found it incredible, or at least I can speak for Humanitas Gavazzeni (where I work) how it was possible to put in place in such a short time a deployment and a reorganization of resources so finely designed to prepare for a disaster of this magnitude. And every reorganization of beds, departments, staff, work shifts and tasks is constantly reviewed day after day to try to give everything and even more.

Those wards that previously looked like ghosts are now saturated, ready to try to give their best for the sick, but exhausted. The staff is exhausted. I saw fatigue on faces that didn’t know what fatigue was despite the already grueling workloads they had. I have seen people still stop beyond the times they used to stop already, for overtime that was now habitual. I saw solidarity from all of us, who never failed to go to our internist colleagues to ask “what can I do for you now?” or “leave alone that shelter that I think of it.” Doctors who move beds and transfer patients, who administer therapies instead of nurses. Nurses with tears in their eyes because we are unable to save everyone and the vital signs of several patients at the same time reveal an already marked destiny.

There are no more shifts, schedules. Social life is suspended for us. I have been separated for a few months, and I assure you that I have always done everything possible to constantly see my son even on the days of taking the night off, without sleeping and postponing sleep until when I am without him, but for almost 2 weeks I have voluntarily avoided my son nor my family members for fear of infecting them and in turn infecting an elderly grandmother or relatives with other health problems. I’m happy with some photos of my son that I regard between tears and a few video calls.

So be patient too, you can’t go to the theater, museums or gym. Try to have mercy on that myriad of older people you could exterminate. It is not your fault, I know, but of those who put it in your head that you are exaggerating and even this testimony may seem just an exaggeration for those who are far from the epidemic, but please, listen to us, try to leave the house only to indispensable things. Do not go en masse to stock up in supermarkets: it is the worst thing because you concentrate and the risk of contacts with infected people who do not know they are higher. You can go there as you usually do. Maybe if you have a normal mask (even those that are used to do certain manual work) put it on. Don’t look for disease masks. Those should serve us and we are beginning to struggle to find them. By now we have had to optimize their use only in certain circumstances, as the WHO recently suggested in view of their almost ubiquitous impoverishment.

Oh yes, thanks to the shortage of certain devices, I and many other colleagues are certainly exposed despite all the means of protection we have. Some of us have already become infected despite the protocols. Some infected colleagues in turn have infected family members and some of their family members already struggle between life and death. We are where your fears could make you stay away. Try to make sure you stay away. Tell your elderly or other family members to stay indoors. Bring him the groceries please.

We have no alternative. It’s our job. In fact, what I do these days is not really the job I’m used to, but I do it anyway and I will like it as long as it responds to the same principles: try to make some sick people feel better and heal, or even just alleviate the suffering and the pain to those who unfortunately cannot heal.

On the other hand, I don’t spend a lot of words about the people who call us heroes these days and who until yesterday were ready to insult and report us. Both will return to insult and report as soon as everything is over. People forget everything quickly. And we’re not even heroes these days. It’s our job. We risked something bad every day before: when we put our hands in a belly full of blood of someone we don’t even know if he has HIV or hepatitis C; when we do it even though we know it has HIV or hepatitis C; when we sting with the one with HIV and take the drugs that make us vomit from morning to night for a month. When we open with the usual anguish the results of the tests at the various checks after an accidental puncture hoping not to be infected. We simply earn our living with something that gives us emotions. It doesn’t matter if they are beautiful or ugly, just take them home.

In the end we only try to make ourselves useful for everyone. Now try to do it too though: with our actions we influence the life and death of a few dozen people. You with yours, many more. Please share and share the message. We must spread the word to prevent what is happening here in Italy.

It Really Is The Prices, Stupid!

Thursday, March 21st, 2019

Trying to understand American health care these days is a little like trying to do the breast stroke through molasses. A lot of effort for not much progress.

The scope of the issue is vast. In 2017, US health care spending grew 4.6%, exactly double the growth rate of inflation, to $3.5 trillion. In 2018, it grew another 4.4% to $3.65 trillion. That’s 18% of US Gross Domestic Product (GDP). To put this in perspective, consider this: $3.65 trillion is more than the entire GDP economies of Italy and Spain – combined! It is $1 trillion more than the entire GDP of France and  equals that of Germany’s $3.6 trillion GDP.

Each of the health care players say they want to do something about this, just as long as you don’t touch their particular slice of the pie. And, because the health care lobby dwarfs every other one, we’re reduced to nibbling around the edges.

In 2003, Uwe Reinhardt, Gerard Anderson, Peter Hussie and Varduhi Petrosyan published their seminal work, It’s The Prices Stupid: Why The United States Is So Different From Other CountriesThey examined health care data from 30 OECD countries for the year 2000. Here is the basic conclusion from their Abstract:

U.S. public spending as a percentage of GDP (5.8 percent) is virtually identical to public spending in the United Kingdom, Italy, and Japan (5.9 percent each) and not much smaller than in Canada (6.5 percent). The paper also compares pharmaceutical spending, health system capacity, and use of medical services. The data show that the United States spends more on health care than any other country. However, on most measures of health services use, the United States is below the OECD median. These facts suggest that the difference in spending is caused mostly by higher prices for health care goods and services (my emphasis) in the United States.

In 2017, Reinhardt died, after which his co-authors decided to re-examine their original conclusions and publish their findings as a tribute to him. Their new paper, It’s Still The Prices, Stupid, which they published in January, 2019, concluded that their original conclusions were “still valid.”

The conclusion that prices are the primary reason why the US spends more on health care than any other country remains valid, despite health policy reforms and health systems restructuring that have occurred in the US and other industrialized countries since the 2003 article’s publication. On key measures of health care resources per capita (hospital beds, physicians, and nurses), the US still provides significantly fewer resources compared to the OECD median country. Since the US is not consuming greater resources than other countries, the most logical factor is the higher prices paid in the US. Because the differential between what the public and private sectors pay for medical services has grown significantly in the past fifteen years, US policy makers should focus on prices in the private sector.

Another way to look at this is to compare the growth of health care utilization with the growth of prices. This produces some highly informative, surprising and, sometimes confounding, data. For example, from 2012 through 2016, US hospital in-patient prices rose 24.3%, yet in-patient utilization decreased 12.9%. I guess all that hospital consolidation has really lowered hospital prices, hasn’t it? During that period, and due primarily to the opioid epidemic, prescription drug utilization was the only medical service whose utilization rose, and it was up only 1.9%, despite the prices of prescription drugs rising 24.9%.

Question: Who has the most skin in this game?

Answer: Employers and the 156,199,800 people who work for them.

That answer is why I believe Warren Buffet, Jamie Diamond and Jeff Bezos, three major employers, have formed their joint health plan, Haven, and hired Atul Gawande to run it.  They have given Dr. Gawande time and a lot of money not just to slow the spending growth in their respective companies, but to reverse it. Buffet has spoken loudly about how health care costs place America at a competitive disadvantage. He has been vocal in his criticism of Republicans’ devotion to reducing corporate taxes, which, at 1.9% of GDP, are now the lowest among advanced nations and pale to near insignificance when compared to the health care costs borne by employers. He has said, “Medical costs are the tapeworm of American economic competitiveness.” Further, they are a major cause for little or no real wage growth.

More proof for his point: According to the US Census Bureau, employer sponsored insurance plans (ESIs) cover 56% of the US population. In 2018, the year we hit $3.65 trillion, the average annual premium for a family in an ESI was $19,616, of which employees paid an average of 29%, or $5,688. Employees in family plans also had an average deductible of $2,788, plus co-pays. So, even without the co-pays, employees are paying more than $8,000 for an ESI family plan. In 2019, we will blow through $20,000 for the cost of an ESI family plan. This is patently unsustainable and leads to two inescapable conclusions: First, Washington has not fixed this, and, given past experience, it is doubtful it ever will, regardless of efforts by progressives. Second, employers are the only people with the leverage and urgent incentive to do anything constructive. They need to stop worrying about corporate taxes, get on the Buffet, Bezos and Diamond bus, and throw all the muscle they have at the American health care fiasco.

 

Rob Restuccia Passes The Torch

Monday, February 25th, 2019

Every once in a while in life, if you’re lucky, you’ll come to know and work with a person whose commitment to service, whose dedication to justice, whose devotion to helping the less fortunate among us live full and healthy lives is both humbling and inspirational. For me, such a person has been Rob Restuccia.

Rob is a founder of Health Care For All and Community Catalyst. Health Care For All was instrumental in making Massachusetts a first-in-the-nation model of near-universal health coverage in 2006, and Community Catalyst played a vital role in the passage of the Affordable Care Act in 2010 and its successful defense against repeal in 2017.

Since late-2003, Rob and I have served together on the Board of Commonwealth Care Alliance (CCA), a Massachusetts HMO serving dual-eligible beneficiaries, meaning they qualify for both Medicare and Medicaid. They are the sickest of the sick and the poorest of the poor, and they represent about 5% of the nation’s population, but consume 35% to 40% of our health care costs. As a founding Board member, Rob has been a constant north star to staying true to our mission. He is one of the reasons CCA has been the highest rated plan of its kind in the nation for each of the last two years. But much more than that, Rob is one of the reasons tens of millions in this country now have health insurance and no longer have to face impending disaster because they cannot afford the health care they need.

Now, Rob is dying.  Five months ago he was diagnosed with pancreatic cancer, a terrible disease. The cancer was too advanced for surgery. He tried chemotherapy, but that was unsuccessful. So, he has chosen to seek the highest quality of the life that remains, not the greatest quantity.

Today, the Boston Globe ran an op-ed by Rob. It is his farewell, his swan song, and it is beautiful. It is also a clarion call to continue the battle for universal health care, the kind every other developed nation on earth has, except America. It is a call that we treat health care as a basic, human right, not a privilege. If you do nothing else today, please read Rob’s articulate and rational argument for the cause to which he has devoted his life. In the article, he writes, “Though I will not live to see it, I am convinced the march toward universal, affordable, equitable, quality health care is unstoppable. The next generation of advocacy leaders will continue the work I leave unfinished.”

We will all be poorer with the passing of Rob Restuccia, whose entire, all too brief life has been dedicated to service to others. We can learn much from this brilliant and accomplished icon, both in the way he’s lived, and now in the way he’s dying.

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

Thursday, February 14th, 2019

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

Wednesday, February 13th, 2019

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

Friday, February 1st, 2019

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!