New Zealand is the only other country in the world that allows direct-to-consumer marketing. Those Lipitor ads, the Mucinex boogers — they don’t exist outside of those two countries. The pharmaceutical companies claim that their advertisements provide important educational value to patients. “They can learn about diseases they might have!” the companies say. I say humbug.
Patients learn nothing from these ads, besides seeing ridiculously attractive, healthy-looking, active people pretend to have any number of diseases. I’ve said it before–if the companies were truly interested in educating patients, they would teach them about any number of topics that many patients do not understand. Instead, they hawk products half the time and quickly ramble a list of side effects with the other half left.
Remember–the Pharma corporations are responsible to their shareholders, not the public. Their goal is to make more money, by selling more pills. They do not “educate patients” because it’s good for patients. They “educate patients” because it’s better for their bottom line. Do we not trust physicians to make accurate diagnoses that we need patients to ask for Lipitor?
Ban direct-to-consumer advertising.
If not that, make the field “direct-to-consumer educatisng.” 95% of your advertising time teaches the public how scientific studies work, or what a cardiac stress test does, or why antibiotic resistance is a problem and why doctors don’t like to give out antibiotics liberally, or why CT scans aren’t always a good idea, or why vaccines are safe. There’s an almost limitless number of topics physicians are repeating over and over to patients. In the last 5 seconds, you get to flash your drug logo. “Brought to you by Pfizer.” Put out or get out.
Hey Jon Marshall, DO, thanks for recommending Hydroxycut! I know you’re just a “Resident Physician” as the commercial says (funny, it didn’t mention you’re a radiologist in training) but you radiologists interact with patients and advise them on weight loss pretty consistently, right? Look, you’re pretty hot and all, and I’m sure that helps sell the pills, but seriously, dude. You chose medicine for “the science behind it. I also like dealing with people and helping them,” and you’re hawking a product with pretty iffy science behind it (Hydroxycut was sued for making false statements about it being “clinically proven” and paid to settle). And you have to admit, it’s kind of funny that you “like dealing with people,” so you went into radiology.
(Side note: what’s with Midwestern University DO School? They seem to be churning out the resident DO physician product marketers–it’s where both Dr. Marshall and Dr. Swanson went.)
To be fair, at least the Hydroxycut site gives references for their scientific research (in one study of 30 whole patients, another with 60) plus two studies that seem to be about caffeine and green tea.
Hydroxycut isn’t limited to DOs, however. They’ve got Nick Evans, a MD and attending orthopedist/sports medicine man hawking the product, too. (At least his specialty is related to exercise and weight loss.) Dr. Evans, dude, you look huge! (My favorite is the Bodybuilding Anatomy book with his head photoshopped on a drawing of a bodybuilder torso.)
I just suffered through a stupid Zetia ad featuring this lady:
who goes on to say something to the effect of, “My doctor tested my cholesterol, and it was a little higher than we wanted, so he prescribed Zetia!” And now my life is perfect! (Okay, the last line is my cynicism talking.)
Now, I guess I don’t know all her risk factors, but for an otherwise healthy woman, with a cholesterol level “a little higher” than “we wanted,” I’m pretty sure her doctor should have tried 12 weeks of diet and exercise changes first. Or maybe the guidelines have changed, and the Zetia advertisers are more up to date and know more than me. It’s happened before, I’m sure.
This is exactly the reason every other country has banned direct to consumer snake-oiling advertising (besides New Zealand)–it doesn’t present information fairly or in accordance with national guidelines, doesn’t show patients that your doctor actually has to do some quick thinking and calculating to determine if drugs are the right answer for you, and that drugs aren’t always the right answer for you to begin with. (Drugs have SIDE EFFECTS and can do BAD THINGS to people.)
Let’s either jump on the Evidence-Based Medicine bus–and make our advertisers and patients do so, too–or else it’s going to just be another thing we have to explain to our patients and educate them about. Or, I guess, the other option is to just prescribe drugs, admit patients, and do procedures when we feel like it or think it might be a good idea.
On that note, I think I’ll go ahead and get my appendix out, while I’ve got a few free weeks before I’m back in clinics.
People seem to be taking sides in our little medblogger health care debates; I hear a lot of people that would be unhappy with a single-payer solution, but not a whole lot of other ideas to fix our health care system (ie: more negative ads than positive ones). The fundamental thing I don’t understand from libertarians is this: what’s a better option? Libertarians would have you believe that if we all just were responsible for our own health care costs, we would decrease our spending and la la la everything would be okay. But that’s not going to happen.
We have a law on the books saying that any ER has to screen patients who walk through the door. Now, you can take this law and do one of two things with it:
1) Keep it, and deal with the consequences that it creates.
2) Repeal it. (But let’s be honest, people, no one but wealthy crazies actually believes that this is reasonable policy.) So we repeal it, and ERs are allowed to turn away emergency patients (or patients who think they might be emergencies). We’re going to let people die on the streets? This would never, ever happen, and if it did–talk about health care revolution.
So here we are. We as a society have agreed that we will take care of the acutely ill, no matter the cost.
From where I’m standing, then, if we’re going to take care of the acutely ill, we might as well keep societal costs lower by preventing people from becoming acutely ill (or from developing the consequences of chronic illness). Am I crazy? Am I missing something here? You can’t tell me that our system makes sense in this way. We will allow an uninsured diabetic to go years without any preventive care, because lack of ability to pay, but once his foot becomes necrotic and he needs an amputation, and gets an ICU stay for becoming septic–oh well, let’s definitely pay for that!?
(A note: single-payer critics will say that single-payer causes tax increases; while this is technically true, as money would be directed to the government, it would not be new money, it would essentially be the same money that employers are already paying for health insurance to HMOs right now.)
Single-payer would cover everyone.
Single-payer would slow costs.
Single-payer would allow people true choice–to see any doctor they wanted, provided that the doctor was available to see them.
Single-payer would allow for lower prescription drug costs.
Single-payer would not “cherry pick” healthy people; single-payer would eliminate the American concept of “pre-existing conditions.”
Look, if you have a problem with the “political feasibility” of single-payer, that’s fine, we can debate that. If you’re weary of allowing a government entity to set all health care reimbursement, that’s fine, we can debate that. But to stick your thumbs in your ears and ignore that we’re already ready to pay for emergency care, because of the consequences of the alternative is just stupid, plain and simple.
Dr. Sid takes on direct to consumer advertising, which apparently is now advertising implantable defibrillators. I don’t blame him. All of it should be banned–only the US and New Zealand allow it–to our detriment.
A new antibiotic compound has been found in wallaby milk: “Compound AGG01 was found to be effective against a relative of the hospital superbug MRSA, or golden staph, as well as ecoli, Streptococci, Salmonella, Bacillus subtilus, Pseudomonas spp, Proteus vulgaris, and Staphylococcus aureus.”
No word if it’s actually safe in humans yet.
April 23rd, 2006
Paduda on Medicare Polls:
Part D enrollee satisfaction: “This is called adverse selection, and is the main reason the program will not be successful over the long term. Simply put, the ones who sign up are the ones who will get more in benefits than they will pay in premiums.”
April 13th, 2006
The Draw of Free Stuff:
Maria’s piece, The Drug Pushers explains the ease by which one can have the drug companies pay for everything you could need as a doctor. (Stanford is considering banning all drug rep materials; I hope it passes.)
Drug companies are beginning to realize that a huge proportion of patients aren’t taking their medications as often as they’re prescribed. And they’re finally concluding that they could make more money if people actually took them all daily. An NYT article looks at the trend, including drug companies calling patients and encouraging them to continue taking their meds. It brings up a number of good points: what happens when the medication goes generic? If you switch to a different version of the same medication class, does the patient get kicked out of the program?
I’ve always thought that drug companies should be handing out free weekly or monthly pill boxes to patients with polypharmacy to increase adherence (it’s adherence, NYT, not compliance), but that’s just me.
Item 1: Medicare is paying employers to maintain their retirement plan health care benefits, to the tune of $4 billion. These health benefits compete with Medicare Part D benefits.
Item 2: We already subsidize health care insurance, primarily through making business expenses for health insurance tax-deductible.
Item 4: Our President’s plan to fix the health care system, Health Savings Accounts, is primarily targetted toward the middle- and upper-classes, those who already have health insurance. It also ignores the fact that approximately 80% of health care costs come from approximately 20% of patients (the really sick ones).
What’s next? The government subsidizing the drug companies for taking part in the Medicare D benefit?
Is it just me, or does it seem like our leaders are just setting up the government to fail?
Read’em and weep, common logic. If you drop co-pays for the sickest and most at-risk people, you save tens of thousands of hospitalizations and thousands of ED visits. A RAND study.
“I’m hearing shock from (state) Medicaid directors that we’re getting better prices than they are,” she told UPI. “I don’t know of any other government program where the real costs are less than the estimates,” she said, arguing that the plans are offering “affordable products” with low premiums and low deductibles. -Karen Ignagni, president of the health insurance association
If you haven’t been following the news, the Medicare Part D drug benefit is turning out to be a disaster–millions of seniors aren’t getting their prescription drugs, for any number of reasons: they’re not listed in the computer, the computer is giving pharmacies wrong information about costs, or the computer systems just aren’t working at all. Pharmacies are on hold for 2-3 hours for one single patient, and states are declaring public health emergencies and paying for the drugs themselves. Recently, the President told insurers the system isn’t working, and that, at least temporarily, there needs to be price controls.
This is a brilliant system for Pharma. They practically wrote the bill, saying how great it would work, and now private insurers and the federal government, who have to implement it, take the blame for a crappy system. Bravo Pharma, bravo! Jolly good play there.
I’ve been in contact with a really great Medicare patient advocate for the state of Arizona, and he’s filled me in on why some drugs aren’t listed in the Medicare Drug Calculator:
In your tutorial, you mention that you have questions with the “Enter My
Medications” section. First, the Federal legislation expressively
prohibited Medicare Part D from providing barbiturates and benzodiazepines,
so they won’t show up. Second, an approved plan is only required to provide
two drugs in each treatment category, so many drugs are not on many of the
formularies, although they are also required to provide “substantially all”
drugs available for the treatment of Cancer, AIDS, and a list of other
conditions.
As all of us who’ve used the Plan Finder know, the prescription information
that the person provides us (even with their prescription bottles in front
of us or a pharmacy printout) doesn’t always match what’s available in the
Plan Finder’s prescription drug drop-down lists. A weird example is that I
have sometimes found a brand name only by going to the name of the generic,
and vice versa.
There is a significant challenge to us who don’t have a medical background.
I can sometimes narrow the specific form of a drug down by going to
http://www.rxlist.com/ and finding how the drug is provided, as I don’t have
a current PDF. As a fictional example: I find in the drop-down list that
there are both an “EX” form of a drug and a “TG” form. Looking at this
website (or PDR, or whatever), I see that the “EX” is available in 2.5, 5,
and 10 mg tablets, whereas the “TG” form is in a 10 ml vial, and the
prescription that the person is taking is 5 mg.
I always tell the person being screened when there is uncertainty as to one
of their prescriptions or when I have to leave a drug off the list. I
recommend that they contact the company(s) directly and find out how those
prescriptions will be handled, before enrolling.
Also, here’s a list he sent me of drug classes that have to covered under Medicare Part D:
REQUIRED COVERAGE FOR “ALL OR SUBSTANTIALLY ALL” MEDICATIONS FOR:
Cancer medications
HIV/AIDS treatments
Antidepressants
Antipsychotic medications
Anticonvulsive treatments
Immunosuppressants
(source: CMS webcast PowerPoint slide 4, 9/28/05)
MEDICATIONS EXCLUDED FROM COVERAGE UNDER MEDICARE PART D:
Drugs for:
Anorexia, weight loss, or weight gain
Fertility
Cosmetic purposes or hair growth
Symptomatic relief of cough and colds
Prescription vitamins and mineral products
Except prenatal vitamins and fluoride preparations
Non-prescription drugs
Barbiturates
Benzodiazepines
(source: CMS 2005 REACH training, Module 10, May 29, 2005, PowerPoint, p.
59)
Today is one of those days that makes me want to move to Canada, France, Spain, or Great Britain, because I’m just utterly disgusted by the Almight Dollar. I’m probably mesmerized by dreams of a greener grass, but today I’m willing to risk it–the weeds we’ve got here are downright rotten.
And then I go read Kate’s find that we’re wasting hemorrhaging (that means we’re really wasting) money on the new Medicare Drug benefit. Had we just expanded the VA system, senior medications could have been automatically available and at hundreds of dollars per year of savings. (This matters a lot when you’re on a fixed income.) Note: ask your doctor if there are alternatives to the medications you’re on. For example, the “Protonix” example given could be changed to omeprazole (Prilosec), a much cheaper alternative drug in the same class as Protonix and nexium.
And then to top it all off, I go see Syriana. A perfect end to a anti-American day.
I’m a firm believer in the mantra that you can judge a society by it treats its most vulnerable members, and frankly America, we’ve earned an F.
So the theme is intimidation, coercion, and/or threatened punishment of health care professionals who dare to speak out about dangers of drugs or potential reseach misconduct of pharmaceutical companies. Particularly distressing was that in two cases (but presumably not that of Dr. Topol, to the credit of the Cleveland Clinic), pressure by a commercial entity apparently resulted in adverse action by the the professional’s employer, even though the employers in these cases, a UK university, and a US federal agency, ought by their very natures and stated missions to protect the rights of their professional employees to honestly communicate about scientific and medical matters.
When do I have to decide by?
You have until December 31, 2005 to enroll in a plan that starts January 1, 2006. But May 15, 2006 at the latest, if you’re a current Medicare beneficiary. If you become Medicare-eligible in the mean time, or after these dates, you have 7 months from your 65th birthday to enroll.
What happens if I enroll after that?
Unless you’re already in a drug coverage plan (from a pension benefit, for example) that is certied as good or better than Medicare Part D, your monthly premium can increase by at least 1 percent per month of delay.
What if I start a new drug that isn’t covered under the plan I signed up for?
Your doctor can petition for an exception. The plan has 72 hours to determine if it will grant an exception. Denials can be appealed, but it could take awhile.
Can I change my plan?
Once a year, from November 15 to December 31, you can change to a new plan. You can also change if you enter a nursing home or move to an area that your current plan doesn’t cover.
Will co-pays go up?
The plans can increase co-pays or drop coverage, but they have to give a notification 60 days in advance. Unfortunately there’s no choice but to pay this increase, although a vice president of Humana claimed this “would be unlikely,” unless a drug manufacturer started increasing the drug cost.
Zegerid is one of those bullcorn “me too” drugs in the worst kind of way. If massive advertisements for it start as the “latest treatment for heartburn,” it’s best to just put your fingers in your ears and shout “La la la, I can’t hear you la la la!”
Health Care Renewal has a great writeup on it; it’s essentially the exact same thing as over-the-counter Prilosec or prescription Nexium, just mixed with baking soda, and dissolvable in water. (What a breakthrough! Congratulations, Pharma!)
Although 42 doses of over-the counter omeperazole [Prilosec/Nexium] costs about $25 at retail, Santurus is selling 30 doses of Zegerid for about $140.
“That’s a lot to pay for baking soda,” says the significant other.
I had dinner tonight with The Malcolm Gladwell, and I say “The” like David Letterman says “I like The Doritos,” as if he’s a household name, because, well, he (Malcolm) kind of, sort of… is. (My mom told me to say to him for her.) He’s the guy with the big hair that wrote Blink and The Tipping Point and writes for The New Yorker. He is long-time friends with a friend (Ann and husband Chris) and she was kind enough to invite me along to a dinner. He’s in the area speaking today with Atul Gawande, another literary idol (he wrote Complications: A Surgeon’s Notes on an Imperfect Science) and several other great New Yorker pieces.
So I’m kind of totally geeked-up excited about meeting him as it were; and he’s, like, pretty normal. Felt totally comfortable talking to him (the wine helped), and he was great to talk to. He’s interested in health care, so that definitely helped too; I find myself with less and less ability to relate to anything non-medical. I explained my cognitive dissonance theory to him, it being my latest theory to try to figure myself out, and the night progressed through health care reform, when it will happen, how it will happen, and even a little debate on Medicare Part D and the pharmaceutical industry. Although I still don’t fully see eye to eye with him on it, he convinced me on some points, and I’ll admit I didn’t know that generics were significantly cheaper here in the US. He also has an opinion on when health care reform will take place in the US, but I don’t want to spoil it if it’s his next article. We also talked about board game strategy, the UK version of The Office, and I ended up doing my terrible Cartman impression.
I think I’m infinitely envious of his job (or maybe more Atul’s–if I could read and write on fascinating things, plus do medicine, that’d be the ultimate), but, like a lot of things, it’s probably less fun when you have to do it as opposed to doing it for fun. I think one of his greatest strengths is his ability to take the everyday experience, make sense of it, find some data behind it, and explain all the facets of it. It’s almost like he writes things that you agree with on almost a “gut instinct” level, but then explains your gut away. (Me, I’m trying to lose my gut.)
And the kicker? I email Ann back after the evening thanking her for the invitation, and I get a great one-liner back:
Before we start, I’d recommend getting your pill bottles or list of medications in front of you. And maybe a glass of water. This may take awhile. Here we go, kids:
Hold down the shift key and click on this link. (When I say click, I mean take the left mouse button–or the only mouse button on some computers–and click.) This will take you to the Medicare Calculator and open a new window, while leaving this one open. Here’s a clip of what you’ll see (without the pink and grey box):
That pink and grey box is your key. That usually means there’s something important. Click on that first link, “Compare Medicare Prescription Drug Plans.” That’ll bring you here:
Now click on the orange arrow on the right side of “Find a Medicare Prescription Drug Plan.” Okay so far?
Next, if you’d like, you can enter all your info from your Medicare card in the top area that says “Personal Information.” To enter information throughout this tutorial, you left-button click on the box where you’d like to enter information, and then start typing, just like this one:
For the general search, which will work just fine, click the “General Search” box:
Now it gets confusing. First, enter your zip code in the box. That’s #1 on the graphic.
The next step requires your own personal information. If you have some other way that you get medications–maybe through Medicaid, your previous or current employer, etc, click the appropriate box. For most people, just click the box next to “None of the above.” It’s pink-grey highlighted as #2. (Any box you check takes you to almost the same page anyway. Sigh.)
Next, are you qualified for an extra discount on drugs according to your income and the Social Security Office? If not, click “No,” #3.
Then click continue, #4:
Next, click “Choose a Drug Plan Type.” Keep going, you’re doing great!
Now they want to know if you have Medicare Advantage, also known as Medicare+Choice, which is already helping pay for your prescription drugs now. If you have no idea what I’m talking about, click the lower box, “Search for Medicare Prescription Drug Plans.” Otherwise click the top box. Now you’ll see:
From here, you can start viewing the plans in your area. However, since the best deal you’ll get is based on the medications you take, I’d recommend entering them in the system. If you don’t want to do this, just click “View Plan List.” If you’d like to follow my recommendation, select “Enter my Medications.” Great!
Here’s why I had you get your medicine bottles out: You need to enter the name of each (either the brand name or generic name is fine) in Box #1. The click the button (#2) to add the medication.
If all goes according to plan, the medication will appear down below, in this new pink-grey box #1. If there are multiple medications with the same name, or if the system is confused about a generic name, it’ll make a display like in box #2. Simply click the medication name you wanted, and click box #3. Once you’ve got everything entered and every medicine appears in box #1, click box #4. (Note: some medications will not be in the system, and I have no idea what this is. I tried different medications, spelled correctly, and they couldn’t be found. I’m not sure what to do about this. I’m sorry.)
Once you click the “Continue” box, you’ll stay on the same page, but another box will pop up.
If you’d like to enter your specific medication dosage (10 mg or 20mg or 40mg, for example), click the “Choose My Drug Dosage” button. In the effort of simplification, we’ll skip this step–besides, you can do it later if you’d like.
Likewise, if you want to pick up your meds at a specific pharmacy in your area, you can do that now with the “Select My Preferred Pharmacy.” But note: certain plans may work with some pharmacies and not others. If you want the absolute lowest cost, click “Continue to Plan List.” If you want to pick your pharmacy from one locally, click “Select My Preferred Pharmacy.” Also note: if you want to get your meds by mail, the Plan List page will show you which plans will mail your drugs to you.
Finally! We’re on the list of your plans! They’re sorted by lowest yearly price. The rest of this just explains the final plan page with letters:
A: Click this box and up to 2 others to compare three plans. Click C to do the comparison.
B: Click this box for more options about the plan–the exact costs, how much you could save if you only used generics, enroll in the plan, etc.
C: See A.
D: Change your mind about wanting a specific pharmacy? You can do that here.
E/F/G/H: Here you can update the pill strength of each medication, or add more.
Now, if you want to sort the plans by something other than total yearly price, you can click on the column title and change it. Note that all these numbers really depend on what drugs you take, so it’s important to enter them accurately. Remember, Annual Deductible is how much you pay until Medicare starts paying its 75% for your first $2,250. Monthly Drug Premium is how much you pay per month to take part in the plan no matter how many drugs you use, and Monthly Cost Share is how much you pay as a co-pay when you get the drug.
I really hope this helped someone. Damn long writeup by my standards.
Medicare, the insurance system for folks 65 and older, is about to get another addition tomorrow to provide prescription drugs to enrollees. There’s only one problem: it’s a complete disaster, and should be an embarrassment to every Congressperson that supported it. The following is an attempt to make sense of Medicare Part D in all its bureaucratic glory. I’m trying to write at a level anyone can understand, so you, or your parent, or your grandparent can understand it. It is not simple, and getting frustrated and confused is not a sign of stupidity.
A little background: Medicare has a couple parts. There’s Part A, which covers hospital care, and is pretty much automatic when the clock strikes midnight on your 65th birthday. There’s also Part B, which covers doctor visits, and costs those that signup for it $78 per month. Almost everyone has Parts A and B. There’s also Medicare Part C, which was passed in 1997 by the Newt Gingrich Congress, which allows people to enroll in an HMO for their Medicare, which can provide them with prescription drugs. (AKA Medicare Advantage, Medicare+Choice.) It could be its own post, so I won’t delve too far. Now, most folks love Parts A and B, which, not coincidentally, most people have. You turn 65, you check a box on a form, send it in, and you’re covered if you go to a doctor or have to be hospitalized. Easy as pie. Unfortunately, Medicare didn’t cover drugs, which are commonly needed by seniors, so the people said “We need drug coverage.” And All Was Good Bad.
But this new Medicare Part Disaster is no simple box checking. A senior can’t just say “Yes, I’d like cheaper medications,” and then the government does that whole “Helping the People” thing, because that’s the whole reason the People wanted the government in the first place. Medicare Part D requires a senior to compare plans–up to 85 in one area–and choose one based on a number of different factors and numbers. (It should be noted that this system was made under the guise of choice–the bill was heavily influenced by lobbyists. Take a second and ask yourself about the choice: do you honestly care which company provides your medications? Probably not. You just care that you can get them cheaper and have access to them when you need a refill.) You might think that there’s no precedent for such a simple, straightforward plan without the bureaucratic nightmare, but it’s not the case. There’s at least two: the Veteran’s Affairs hospital system and the state-run Medicaid program (which provides insurance for the very poor). These systems are not perfect, but their bureaucracy causes headaches for administrators, not for patients. Also note this: the law that made Part D specifically forbids Medicare from using its bulk purchasing power to get cheaper costs on medications for patients, but Medicaid and the VA both do this, too.
So how is this Medicare Part D thing supposed to work? In a perfect world, a person picks a Prescription Drug Plan (PDP) from one of many offered by different companies. That PDP pays for part of their drugs, after the senior pays for some as well. The PDPs differ on how much you pay per month, how much you pay up front, how much you pay per drug pickup, which pharmacies you can get the drugs from, etc. As you can imagine, if you have multiple drugs, and your spouse does too, it can be a total nightmare. But wait Vanna, there’s more: our nifty little terror here has another catch. For the first $2,250, you and Medicare split the drug bill (Medicare pays 75%). After that, for the next $2,850 of drug costs, you, the patient, have to pick up the entire tab. Once $5,100 is reached ($2,250 + $2,850), Medicare kicks back in, paying 95%. People call this donut coverage; you get to eat a bite until you get to the middle, then you get nothing, but then you get donut again once (if) you get to the other side.
Seniors are completely confused by this Medicare Part D. (And if you’re even still reading, aren’t you too?) It’s almost to the point that Jeff Foxworthy could do his redneck routine: “If you’re 65 and have recently pulled out your last remaining hairs, you might have Medicare Part D.” You have people with advanced degrees not able to make sense of it. Heck, I have a background in health policy, I’m two years away from being a doctor, and it’s taken me a good while to figure it out. If you don’t believe me, see Medicare complexity may scare off seniors or Confusion Is Rife About Drug Plan as Sign-Up Nears. Plus: A classic “screw you, seniors” quote from Michael Levitt, Secretary of Health and Human Services, who oversees Medicare: “Health care is complicated. We acknowledge that. Lots of things in life are complicated: filling out a tax return, registering your car, getting cable television. It is going to take time for seniors to become comfortable with the drug benefit.” Mikey, Mikey, Mikey… those things are complicated, but they shouldn’t be. That’s no excuse.
I hesitate to even recommend the Medicare website, as it’s its own disaster, but I don’t like most of the other websites out there, and they don’t have a formulary list out there. Terms (also taken from here, and then I’ll explain the Medicare calculator. (USA Today has a decent writeup, too.)
Formulary
A list of drugs that a company or plan decides it will carry. If a drug is “off-formulary,” generally your doctor has to make a special plea to use it and has to have a good reason. You also might have to pay more for it.
Deductible
What a Medicare member pays before drug coverage kicks in. Can be zero to $250 a year.
Medicare Advantage
Managed-care plans, such as an HMO. Medicare Part C. The plans may provide more services than traditional Medicare, but may limit members to certain doctors and hospitals.
Premium
A monthly payment for insurance.
Quantity limits
Dispensing limits on the quantity of a drug that can be prescribed each month.
Step therapy
Step therapy means a patient must try a lower-cost, often generic, product first. If it isn’t effective, the patient then “steps” to a different, often more expensive, drug.
Co-Payment (Co-Pay, Co-Insurance)
Amount you pay to get a drug after you’ve paid your deductible. Some plans have one flat rate, others have different rates based on the type of drug (brand name vs generic, newer vs older, etc)
Blogging is probably like sending angry emails: you should wait until you’ve calmed down. But I just can’t help it right now. I’m livid.
So I’ve become something of a patient advocate recently with all this geriatrics and frail elders and polypharmacy and whathaveyou, so I thought it’d be a good idea to try to get a grip on the Medicare Part D stuff that’s going around to physicians and Medicare recipients. (My father and grandma tried to attend an information session, but it was so crowded even at the encore performance that they couldn’t get in. Note: this is not a testament to how popular the new plan is; it’s a testament to how damn bureaucratic, confusing, and complicated the thing is.) So I do a Google search for medicare part d to get some general results. I get a ton of ads (a clear sign that there’s money to be made by all comers), and I click on some ads, some links. A mish-mash of everything to get an overview, and possibly recommend a site or two to my one or two readers.
I come to my first site, and this is the one that drives me over the edge: AARPMedicareRx.com. I see AARP in the URL, and assume it’s a special site the AARP has created to help its members. Then I see the AARP logo in the top left corner, and assume I’m right. I click on “Learn the basics,” and get this first paragraph:
If you’re eligible for Medicare, you have a new option for getting coverage to help with the cost of prescription drugs: AARP MedicareRx Plan is a prescription drug plan that is approved by Medicare. This national plan is provided by United HealthCare Insurance Company* and begins January 1, 2006.
I’m confused. “What? I thought there were multiple options for the Medicare Part D plan, not just one.” I re-read, I scroll down to the asterisk, and reailze I’ve been had. This is not an AARP site at all; no, it’s a United HealthCare Insurance Company website with an AARP (“pharmacy services” bullshit) logo. And if a third year medical student with a major in health policy and a pretty good understanding of the US health care system makes this mistake, you can bet countless others will, too. I’m sure that’s the goal. Show the AARP logo so you get the confidence of the AARP, then tell consumers there’s *one* new plan to help people out.
I’m disgusted. If anyone knows who I could contact to complain about this blatant deception, please let me know. (Isn’t this what the copyright laws were supposed to be for? Protecting consumers from misleading or fraudlent information?)
Polypharmacy is the taking of multiple medications for multiple medical problems. My winning patient so far had 24 when I saw him in clinic on Wednesday. If anyone honestly thinks that patients are taking all of those medications, with all of their different schedules (two of this one in the morning, 1 at night; 3 of this one every 8 hours; one-half tab of that other one every day), they’ve got to be kidding themselves. How many of us can reliably even take a course of antibiotics for 10 days?
Prevention is the only solution, people. Eat better, exercise more, stop smoking, and wash your hands. That’ll lead you to a healthier life than any pill.
One of our national pimples is coming to a head, and it’s pitting those that understand medicine against those that don’t. The former group understands that there’s never a free lunch; that you don’t get something for nothing; that everything in medicine is a trade-off between risks and benefits. The latter group expects a perfect pill for every disease (or even just a pill for every disease).
An attending that I’ve really come to respect over the past weeks made a similar comment out of the frustration with Mexican immigrant family. The boy in the family wasn’t taking his anti-seizure medication regularly (which is important, both because it prevents seizures, which can be dangerous to the patient, and because it’s dangerous to quit an anti-seizure medication cold turkey). My attending, himself an immigrant, said “there was a cultural problem,” but I now think I see what he means.
Until we develop the perfect pills and vaccines and surgeries without any risks, side effects, or complications, everyone must understand this simple fact: everything in medicine is a trade-off between risks and benefits. We do our best to minimize these risks and maximize these benefits as physicians–by doing research to discover which drugs work better and which operations are safer, but even we cannot prognosticate. Leave that to the groundhogs. We can tell you with X percent certainty that a drug will work, or that Y percent of patients will have an infection after surgery, but right now, we don’t know which people are which, in most cases.
That’s the tough part about medicine: we do all this research and publish all this crap to do our best to predict the future; we’re the ultimate in control freaks. We want a good outcome for our patients, so we study and crunch numbers to try to have more control over the outcome, but nothing’s for certain. Life’s precious and fragile. We’re doctors, not miracle workers.
Now, this is no blame-free mantra. As physicians, we must make sure patients understand the above simple fact. But we must also provide them with as much information as possible, in as easy to understand format as possible. And, as we have learned from the Vioxx disaster, we must not allow any possible risks that are known to be hidden. I’ve spoken with several patients in chronic pain with stomach problems (the only group Vioxx should have been targeting) who say that they’re very upset Vioxx was taken off the market: it was the only drug that helped them. They said they were willing to take the risks of Vioxx; it should be each person’s choice.
Osteoporosis is a common disease of bone wasting, predominantly in older, post-menopausal women. It’s an important disease mostly because it predisposes people to bone fractures (hip, femur) after falls, and breaking a bone late in life is correlated with poor recovery outcomes and morbidity.
So we’ve got Fosamax (alendronate) that many people take to prevent bone loss, but it turns out to be a pretty caustic molecule. So caustic, in fact, that you have to take it standing up, and stay upright for an hour after you took it, without food, and with a big glass of water. “After swallowing the tablet, do not lie down, remain fully upright sitting, standing or walking, for at least 30 minutes and until after you have eaten.”
If we can prescribe behaviors associated with prescriptions, I’ve got an idea for an excellent new blood pressure medication: a sugar pill that must be taken along with an hour of playing with a pet. I’m going to make millions.
One of the leading Eli Lily researchers on PTH spoke to us yesterday about PTH and its actions. A good lecturer, but raised a couple thoughts in my mind:
Should companies be able to patent drugs (hormones) we make naturally in our own bodies? Sell it, fine, but patent it?
After he talked about the wonders of PTH (and glossed over calcitonin), I would’ve appreciated it if he had told me that it’s been found to cause osteosarcoma in rats. While there’s no indication that it causes bone cancer in humans, it seems a little suspect that we had to learn the fact from our pharmacology lecture today.
In an article about the FDA and its internal conflicts, a Stanford professor is quoted as saying he was threatened by a Merck veep that if he spoke out about Vioxx, his academic career could become much more difficult:
Dr. Gurkirpal Singh, an adjunct clinical professor at Stanford University, said at the hearing that Merck scientists had tried to intimidate him after he publicly raised questions about the effects of Vioxx.
Dr. Singh, a rheumatologist and science officer of the Institute of Clinical Outcomes Research and Education in Woodside, Calif., said: “I was warned that if I continued in this fashion there would be serious consequences for me. I was told that Dr. Louis Sherwood, a Merck senior vice president and a former chief of medicine at a medical school, had extensive contacts within academia and could make life very difficult for me at Stanford and outside.”
Now, here’s my question: who’s the doc at Stanford that Sherwood thought would be willing to damage Singh’s career?
The Wall Street Journal is reporting that emails from the 1990s show that Merck was already concerned about Vioxx’s cardiac risks back then. What a shame. I usually think of Merck as being a little more ethical than the other drug companies. Guess I was wrong.
I have a confession to make. I am a drug company executive who believes we should legalize the reimportation of prescription drugs. I know that I have a different opinion from that of my employer on this matter, but to me, importation of drugs is about much more than money; it is about saving American lives.
According to a study by the Kaiser Family Foundation issued in 2000, 15 percent of uninsured children went without prescription medication in the previous year because of cost, 28 percent of uninsured adults went without prescription medication because of cost, and 87 percent of uninsured people with serious health problems reported trouble obtaining needed medication. We have 67 million Americans without insurance for drugs, according to the foundation. They pay cash – full price – and can’t always afford life-saving drugs. American drug prices are about 70 percent higher than in Canada and almost twice as high as in Europe…
Every day Americans die because they can’t afford life-saving drugs. Every day Americans die because Congress wants to protect the profits of giant drug corporations, half of the top 10 of which are French, British and Swiss conglomerates.
I have another confession to make. Americans are dying without the appropriate drugs because my industry and Congress are more concerned about protecting astronomical profits for conglomerates than they are about protecting the health of Americans.
Dr. Andrew F. Calman of San Francisco, an ophthalmologist who pushed for the new policy adopted by the medical association, said: “I don’t think it’s a Democratic or a Republican issue. We have the support of doctors from different points on the political spectrum. We’re very concerned about patients’ access to affordable drugs. I have some glaucoma patients who need to take three or four different types of eye drops to avoid going blind, and each medication may cost $50 to $100 a month.”
African sleeping sickness is, pretty much, deadly. You get bit by a tsetse fly, you get a protozoa inside you, and if left untreated, you die. Eflornithine was discovered in the 1990′s–it’s nicknamed “the resurrection drug” for its ability to basically cure comatose people infected with African sleeping sickness. When the disease gets really bad, it enters your brain and spinal cord; eflornithine can also enter the brain and spinal cord however, and kill the protozoa making the patient sick. The other major treatment for severe sleeping sickness is called melarsoprol, but it’s much more toxic and much more dangerous; it carries with it a 4-12% risk of killing the patient.
So we’ve got a pretty good drug for treating this serious, fatal disease, and it has few side effects (sore throat). However, it’s surprisingly expensive to make, and since the countries with sleeping sickness are primarily poor, developing nations, drug manufacturers stopped making the drug. No big deal. Sleeping sickness only affects 500,000 people annually. Hi, sarcasm.
Lucky for those dying Africans, eflornithine has a new market: slowing the growth of unwanted facial hair. Personally, I find it disgusting that we went 6 years without a better drug with less side effects (and mortalities) because it wasn’t profitable ($12.5m is pennies for Aventis). But I find it absolutely disgraceful that the unwanted facial hair drug, Vaniqa, advertises using what appears to be a tsetse fly on a woman’s face, as well as other bugs. The quote on the homepage sums it up nicely:
bq. What a burden that has been lifted from my life! I feel so free now to be who I really am. I’m not at all self-conscious with people.
Is this how far we’ve come? The burden of facial hair is more important to us than totally preventable deaths in Africa? We have the means, but not the will to do it.
After a glowing review of Angell’s book on Amazon.com (quote: “[The drug companies] have antagonized grannies all over the US with their work to stop reimportation of cheaper drugs into the US, a practice that has been in place for many years in Europe. And anyone in marketing or public relations can tell you that no money in the world can help you win against millions of mad grandmothers.”), Peter Rost, a VP at Pfizer, spoke out in support of reimportation, breaking ranks with Pharma’s official position of “drugs from Canada are unsafe!”
bq. We have to speak out for the people who can’t afford drugs, in favor of free trade and against a closed market. During my time responsible for a region in northern Europe, I never, not once, heard the drug industry, regulatory agencies, the government or anyone express any concern related to safety. And I think it is outright derogatory to claim that Americans would not be able to handle reimportation of drugs when the rest of the world can do this.
Pfizer’s official line: “We have a clear and consistent policy on importation. We believe it puts the health of patients at additional risk.”
Rost was previous demoted by Wyeth for telling superiors the company was defrauding foreign governments.
Peter Rost, folks. Pharma, please keep hiring him when he gets fired from Pfizer.
I finished Marcia Angell’s buzzworthy The Truth About the Drug Companies a couple days before school started, and highly enjoyed it. I’ve wanted to write a bit on it, but never had the time. (I still don’t have the time, but whatever.) Derek Lowe has a good counterargument, and I think he’s a pretty honest, genuine researcher.
Angell makes the case that Pharma isn’t all that innovative. Every company wants to have a cholesterol-lowering drug (statin), every company wants its own Viagra. These are called “me-too” drugs. While I _do_ think there are *way* too many “me-too” drugs, I don’t think Angell acknowledges the fact that it’s good to have several versions, to account for genetic differences in patients, allergies, adverse side effects, etc. (She does acknowledge this, but too briefly in my opinion.) But the numbers don’t lie:
bq. Of the seventy-eight drugs approved by the FDA in 2002, only seventeen contained new active ingredients, and only seven of these were classified by the FDA as improvements over older drugs.
I think Angell’s examination of Pharma R&D is pretty good, too. I’m 100% sure that Dr. Lowe does quality work, and necessary work for bringing new drugs to market, but I think he downplays the importance of basic science research. The fact is that drugs _could not be discovered_ without the basic science done by universities, funded by the NIH (and therefore, taxpayers). She also goes through the processes by which AZT, Taxol, Gleevec, and Epogen. And two more bits:
bq. A recent study published in the journal Health Affairs reported than, in 1998, only about 15 percent of the scientific articles cited in patent applications for clinical medicine came from industry research, while 54 percent came from academic centers, 13 percent from government, and the rest from various other public and non-profit institutions.
bq. An unpublished internal document produced by the NIH in February 2000… revealed similar percentages. The NIH had selected the five top-selling drugs in 1995 (Zantac, Zovirax, Capoten, Vasotec, and Prozac) and found that sixteen of the seventeen key scientific papers leading to their discovery and development came from outside the industry.
It turns out that drug law allows the NIH to require drug companies to make drugs licensed from it “available to the public on reasonable terms,” but the NIH doesn’t enforce this. Angell also notes that the “$800 million per drug for R&D” number circulated comes directly from what Pharma told the researchers it cost–without releasing the documents for verification. If I were Pharma, I’d inflate my numbers, too. (The number is also doubled to include “capitalized cost,” as if the drug companies could be investing their money elsewhere instead of investing in R&D.)
We could argue R&D all day, but I think Angell is strongest in attacking the marketing procedures of Big Pharma. She goes after the slimy practices of patenting metabolites or isomers and marketing them as new drugs to consumers to create demand. (Nexium is the active isomer in Prilosec; Nexium was developed as Prilosec’s patent was running out. Clarinex is the metabolite created *by the body* when it digests Claritin. It was made for the same reason as Nexium.) One of the most amazing statistics in the book–Pharma has 88,000 sales reps currently; that’s one for every 5 or 6 doctors in the United States. Imagine if textbook publishers had a sales rep for every 6 teachers trying to push why their textbooks are better. If it’s a good drug, and effective, does it really need all this marketing?
Other good points:
* Pharma basically controls medical education, but they’re not in the education business. They’re in the drug-selling business. If they were in the business of education, they wouldn’t be giving it away for free. Pharma usually contracts out to medical education and communication companies (MECCs) to prepare the teaching materials, but they advertise to Pharma like this: “Medical education is a powerful tool that can deliver your message to key audiences, and get those audiences to take action that benefits your product.” Real educational.
* Pharma has more lobbyists in Washington DC than there are Congresspeople.
* Pharma created the fake group “Citizens for Better Medicare,” spending $65m to fight drug price regulations.
* Donald Rumsfeld was CEO, president, and chairman of a major drug firm. I had no idea!
Angell makes some good suggestions for improving the system: She notes that drugs should have to be compared to existing treatments. Right now, if your drug is any better than a sugar pill, it’s good enough. She also thinks we should do away with direct-to-consumer advertising (it’s already prohibited in most other advanced countries). We should also change the timing of patents (they should begin when the drug is released to market, not when first discovered).
You might not like some of her points, but I think most are fairly strong. Pharma is either in the business of selling drugs and maximizing its profits, or it’s not. I don’t buy for a second that it wants to provide education to patients or providers.
I think it’s fair to say that when HMOs, pharmacy benefits managers, and drug makers approve of Medicare legislation, the public at large is about to be screwed.
Can we take a look at the big “buying drugs from Canada” debate? For a minute? Please? Okay great. Thanks. I’ll just be a minute.
Let’s look at this completely logically, because right now, it seems like the debate couldn’t be any more ludicrous.
* Big Pharma is, of course, trying to keep this from happening. The US is the only developed country that doesn’t have some sort of bulk-purchasing plan. Hence, Americans pay a hell of a lot more to American companies for their prescription drugs than any other non-American does. (You’d think the way the political climate is, they’d try to overcharge France or Germany. But no.)
* Lawmakers Are Negotiating Import of Prescription Drugs (NYT link) from Canada, and of course, Big Pharma is trying to fight it. (They claim to be concerned for Americans’ safety, since there have been ALL those outbreaks in Canada of fake pills being distributed. Nice try, Pharma.)
* Americans (or our legislators) seem to think we’re so entirely anti-government that we’re willing to buy from for-profit pharmacies in Canada instead of just instituting a nation-wide bulk-purchasing plan here in the US. Note: We already have several, through the VA and the Department of Defense. I’d argue Americans are more anti-getting-ripped-off than anti-government, and if the US government could get us drugs even cheaper than Canada (since we have a larger population base), and have them closer to people (instead of having them shipped from Canada, being able to pick them up down the block), this would be a Good Thing.
What the hell is going on here? We trust the Canadian government, but not our own? We wouldn’t even have to create a new program–just expand one of the current ones. Could we be logical about this? Or even economical? Unless I’m missing something, I’m having a really hard time seeing how buying drugs from Canada, and exporting a gigantic sum of money to their economy is as useful as establishing a similar bulk program here, and keeping the money in our own country. (Sorry, Canada.) And if there’s some sort of “socialized medicine” argument here, hanged if I know where to find it. This is pills, not people.
Now it’s no longer just Pfizer; now Eli Lilly is pissed Americans are getting cheap drugs, too. And according to this Kaiser Network report, GlaxoSmithKline, AstraZeneca, and Wyeth want to rip-off only Americans, too. I’m still trying to figure out why the rest of the world is allowed to buy in bulk and get lower prices, but Americans aren’t. And it’s clearly not an anti-Canada thing, since Lilly is going to restrict Canadian pharmacy purchases to “amounts that Lilly estimates are sufficient to supply the Canadian market only.”
It’s a safety issue, says Lilly. My advise to seniors: watch out for all those counterfeit drugs coming in through the Canadian border:
bq(quote). Lilly officials have tracked a “steady increase” in cases of counterfeit and improperly stored Lilly products coming into the United States. The company’s move was based on recommendations from a Lilly task force formed two years ago to study the issue of drug imports from Canada, Smith said.
Big Pharma plans to stop allowing Canadian pharmacies to buy their supplies of prescription drugs through wholesalers (starting with Pfizer); instead, they’ll have to buy directly, presumably causing huge cost increases. Now, the thing that I don’t get is this: Canada (as well as most countries) has been buying through bulk purchasing for years. It seems like Pfizer’s only *now* going after the pharmacies because they’re now serving Americans (and cutting into Pfizer’s profit margins from Americans who pay waaaay too much for drugs). If Pfizer wasn’t happy about Canada buying in bulk, wouldn’t they have gone after them when they started their medicare program in 1965? So what, Pfizer, you’ll allow Canadians to get their drugs cheaply, but not Americans? Call me crazy, but I think Ann Coulter would call that anti-American, unpatriotic, and treasonous.
This is a medical weblog--a collection of thoughts about medicine, medical training, and health policy--written by a fifth-year medical student.
I recently stopped blogging, as I graduated from medical school and I'm now a physician in my residency training in New York City. But feel free to read and enjoy!
(To get rid of this thing, just wave your mouse over it. Ta da!
You know Airborne, that product “invented by a school teacher” that’s supposed to make you feel all better from a cold? It claimed it had a study done to show its clinical efficacy; 
Hey Jon Marshall, DO, thanks for 
Bodybuilding Anatomy book with his head photoshopped on a drawing of a bodybuilder torso.)
