Saturday, December 14, 2019

Proposals to lower prescription drug prices: too little, too late?

A bright spot in the annual U.S. health spending report published last week by the Centers for Medicare and Medicaid Services (CMS) was a 1% decrease in retail prescription drug costs from 2017 to 2018, due to greater use of generics and a slower rise in brand-name prices. According to CMS, this was the first time that these costs have declined since 1973. A previous American Family Physician Community Blog post described ongoing efforts by physician groups, payers, and government to restrain rising drug prices; a 2017 editorial reviewed actions that individual health professionals could take to help patients; and a 2019 editorial discussed the high costs of insulin and what family physicians can do. It's possible that some of these efforts are beginning to bear fruit.

Prescription drug prices vary considerably across pharmacies, geographic regions, and even within the same town or metropolitan area. A cross-sectional study of cash prices for 10 common generic and 6 brand-name drugs in the fall of 2015 obtained using the online comparison tool GoodRx (which AFP uses to estimate drug prices) found that generic drugs were least expensive in big box pharmacies, followed by large chain (more than 100 retail locations) and grocery pharmacies, while small chains (4 to 100 stores) and independent pharmacies had the highest prices. For example, the mean price of one month of generic simvastatin 20 mg was $35 at big box pharmacies, $42 at large chains, $50 at groceries, $112 at small chains, and $138 at independent pharmacies. Cash prices for brand-name drugs varied less; one month of esomeprazole (Nexium) 40 mg, for example, cost between $302 and $345 across pharmacy types.

The American College of Physicians recently joined a growing number of groups advocating that CMS be given the authority to directly negotiate drug prices in Medicare Part D, which is currently forbidden by law. In contrast, the Department of Veterans Affairs (VA) Health System already controls prescription costs through direct negotiation and a closed formulary. A study in JAMA Internal Medicine calculated that in 2017, Medicare could have saved $1.4 billion on inhalers for asthma and chronic obstructive pulmonary disease by paying lower VA-negotiated prices, and $4.2 billion if it had paid VA prices and instituted the VA formulary.

But what about the pharmaceutical industry's assertion that lower negotiated prices would stifle innovation and reduce incentives for drug development? In a recent commentary, Dr. Peter Bach proposed that CMS adopt a "too little" or "too late" strategy, selectively negotiating prices of drugs that have either received conditional FDA approval based on a surrogate rather than a patient-centered outcome ("too little") or have passed their guaranteed 5-year period of FDA monopoly protection ("too late"). In 2019, if CMS had negotiated the prices of the top 10 most costly drugs in each category down to those in the United Kingdom (an average savings of 57%), Dr. Bach estimated that it could have saved $1 billion on the 10 "too little" drugs and $26 billion on the 10 "too late."

The potential savings are substantial. But compared to the staggering $336 billion the U.S. collectively spent on prescription drugs in 2018, are these proposed pricing reforms too little, too late?


This post first appeared on the AFP Community Blog.

Wednesday, December 4, 2019

The health dividend: reducing medical waste to improve population health

For  most people, the term "medical waste" probably brings to mind images of discarded syringes, soiled gauze and bandages, and garbage containers filled with the ubiquitous plastic packing for sterilized instruments. They probably don't think about inconceivably large piles of money evaporating into thin air. But in addition to having the most expensive health care system in the world, the U.S. also leads the world in wasted health care spending. In a recent analysis in JAMA, Dr. William Shrank and colleagues updated prior estimates based on published literature from 2012 to 2019 and concluded that approximately 25% of national health care spending, or about $800 billion each year, is wasted. The main culprits are administrative complexity ($266 billion); excessively high prices ($231-$241 billion); failure of care delivery ($102-$166 billion); overtreatment or low-value care ($76-$101 billion); fraud and abuse ($59-$84 billion); and poor care coordination ($27-$78 billion).

These are huge amounts of money. When American life expectancy has been falling for three consecutive years after more than half a century of steady increases, it would seem that reallocation to population health initiatives of the portion of health care waste that is potentially recoverable with existing interventions, $191 to $282 billion according to the JAMA study (by comparison, annual funding for the Affordable Care Act's Prevention and Public Health Fund has yet to exceed $1 billion), would go a long way toward addressing the root causes of increasing premature deaths - problems such as poverty, segregation, and low social support which comprise the actual causes of death in the U.S.

So why don't we? In an accompanying editorial, former CMS administrator Dr. Don Berwick hit the nail on the head:

What Shrank and colleagues and their predecessors call “waste,” others call “income.” ... When big money in the status quo makes the rules, removing waste translates into losing elections. ... For officeholders and office seekers in any party, it is simply not worth the political risk to try to dislodge even a substantial percentage of the $1 trillion of opportunity for reinvestment that lies captive in the health care of today, even though the nation’s schools, small businesses, road builders, bridge builders, scientists, individuals with low income, middle-class people, would-be entrepreneurs, and communities as a whole could make much, much better use of that money.

Living in Washington, DC during the Great Recession of 2007-2009, I observed that the only two industries that managed to thrive and expand during those otherwise dismal years were the federal government and health care. While that was good for me personally, as a health care professional then employed by the federal government, it also meant that billions of dollars that otherwise could have contributed to the economy and individual incomes were, as Dr. Berwick noted, "captured" by the health care industry, most clearly in the form of rising costs of health insurance.

After the collapse of the Soviet Union and the end of the Cold War, Presidents George H. W. Bush and Bill Clinton both talked about a "peace dividend" consisting of lower military spending that could be diverted into other government programs, used to pay down budget deficits, or returned to the people in the form of lower taxes. Although it is debatable how much the military-industrial complex really shrunk in the 1990s, the gargantuan health care-industrial complex is likely to be at least as tenacious, if not more, in resisting efforts to reduce wasteful spending in order to generate a "health dividend" for all Americans.

Wednesday, November 27, 2019

Is telehealth good or bad for doctor-patient relationships?

These days, it's hard to open a newspaper or the home page of one's favorite online media source without running across a story about telehealth. Last week, Eli Saslow of The Washington Post gave readers a compelling narrative about "the most remote emergency room," a telemedicine center in South Dakota that provides remote emergency care for 179 rural hospitals in 30 states. As the story ended, one of the center's emergency medicine physicians was trying to coach an inexperienced nurse in a hospital 400 miles away through a difficult intubation of a patient with respiratory failure from pneumonia and sepsis.

Meanwhile, the retailer Best Buy, which in April began pilot sales of a $300 telehealth device kit "that allows consumers to perform medical tests on areas including heart, lungs, throat and ears and connect with physicians to remotely diagnose symptoms," recently announced that it would start selling the kits in its stores nationwide. In a press release, Tyto Care, the kit manufacturer, touted itself as "transforming primary care by putting health in the hands of consumers." And last month, telehealth vendor American Well announced plans to offer virtual consultations with Cleveland Clinic physicians across a range of subspecialties.

These examples illustrate the best and the worst of telehealth innovation in our health care system. Having a virtual critical care physician looking over your shoulder to provide guidance in a challenging medical situation is clearly better than having no help at all. But as rural hospitals across the U.S. increasingly struggle to make ends meet and to recruit new physicians to their communities, it's worth exploring the financial and structural disincentives prevent these hospitals from offering in-person critical care services in the first place.

Similarly, while Best Buy customers are willing to spend $300 (plus $60 per virtual visit) to have 24/7 access to a primary care doc in a literal box, it's fair to question why in Washington, DC, where the physician to population ratio is higher than anywhere else in the country except perhaps Boston and New York City, a new patient still must wait an average of 3 months to get an appointment to see me for primary care. And though virtual consultations for conditions where qualified providers are in short supply, such as opioid use disorder, make a great deal of sense, the rapid spread of telehealth consults is rapidly outstripping the limited evidence that they improve clinical outcomes and patient satisfaction. Rather than consulting their local family physician for a sprained ankle or acne, will patients instead call on a virtual Cleveland Clinic orthopedist or dermatologist?

Unlike direct primary care, where a predictable revenue stream from monthly subscriptions gives physicians the freedom to care for patients in whatever setting is most appropriate, the dominant fee-for-service model is still lagging behind the demand for convenient in-person and virtual care. I am not paid for making a 15-minute followup phone call, much less having a video encounter with a patient. Telehealth has great potential to strengthen the traditional therapeutic relationship between doctors and patients, or weaken it, depending on how this technology is deployed and regulated in the coming years.

Wednesday, November 20, 2019

Caring for military veterans

Although the United States government designates a single day (Veterans Day) to specifically honor persons with a history of military service, family physicians provide care to veterans all 365 days of the year. A review article and editorial in the November 1 issue of American Family Physician discussed selected health issues and resources for the estimated 18 million veterans living in the U.S., most of whom seek primary care in the community rather than at a Veterans Health Administration or military treatment facility. A pocket card developed by the U.S. Department of Veterans Affairs (VA) provides a list of suggested questions related to military service that can help clinicians and trainees take more careful, veteran-centered histories.

Conditions highlighted in the AFP review article included lower extremity overuse injuries, osteoarthritis, posttraumatic stress disorder, moral injury, sexual trauma, traumatic brain injury, chronic pain, depression and suicide. A recently published synopsis of the 2018 VA/Department of Defense clinical practice guideline on patients at risk for suicide provided evidence-based recommendations for assessing for current suicide risk and managing persons at low, intermediate, and high acute risk for suicide. In addition to facilitating access to nonpharmacologic and pharmacologic treatments, the guideline also found evidence to support firearm restrictions and safety counseling; reduced access to poisons and medications associated with overdose; and installing barriers to prevent jumping from lethal heights.

Percentage of Veterans Among the Adult Population
Source: U.S. Census Bureau

In an editorial in the Annals of Internal Medicine, Dr. Edward Manning, a physician-scientist who was an officer in the U.S. Marine Corps prior to medical training, made some personal observations about bridging the "cultural divide" between military and civilian life that can present unintended obstacles to the physician-patient relationship. Dr. Manning noted that "from the veteran's point of view ... all physicians in the military are officers," warranting the formal greeting of "Ma'am" or "Sir." However, "one unfortunate aspect of military culture may be the inherent distrust of physicians," whose physical and mental fitness evaluations can exclude candidates from all or some types of military service (e.g., piloting military aircraft). Family physicians who make the effort to ask patients about their military service and empathize with a veteran's point of view will be better equipped to provide personalized care to this diverse population.


This post first appeared on the AFP Community Blog.

Thursday, November 7, 2019

Family physicians caring for fewer children: reversing the trend

"How did you choose family medicine?" I've lost count of the number of times I've been asked this question by a medical student. The truth is, I entered medical school thinking that I would become a general pediatrician and focus my energies on keeping children healthy. It was only after I realized how much I also enjoyed adult medicine and well-woman care that I decided to enter the only specialty that would allow me to provide continuous, relationship-centered primary care to patients from their first until their last day of life.

In 2005, a Robert Graham Center report, whose key findings later appeared as a Policy One-Pager in American Family Physician, sounded an alarm. The authors reported that the share of children who saw family physicians for primary care had declined from one in four to one in six since the early 1990s. A subsequent article in Family Practice Management (now FPM) explored some reasons for the decline: expansion of the pediatrician workforce; fewer family physicians providing prenatal, newborn, and pediatric inpatient care; and a lack of awareness among the public and the media about the broad scope of family medicine training. The FPM article recommended several strategies for individual family physicians to increase their opportunities to recruit children to their practices:

- Build relationships with Ob/Gyns and pediatricians in your community.
- Heighten your visibility in the hospital.
- Get to know the nurses in labor and delivery and the nursery.
- Don't rely solely on word-of-mouth marketing.
- Talk with patients whose children might be outgrowing their pediatrician's office about transferring.
- Create a kid-friendly environment.
- Make sure your hours and appointment access are sensitive to the needs of young families in your community.

Nearly 15 years later, according to the American Academy of Family Physicians member census, 80 percent of family physicians are still caring for adolescents, while 74 percent see infants and younger children. But a recent population-based analysis of an all-payer claims database in Vermont suggested that family physicians' share of children's health care has continued to erode. Between 2009 and 2016, children residing in Vermont were 5% less likely to be attributed to a family physician practice, a trend that included urban and rural areas. Older children, girls, and children with Medicaid were somewhat more likely than others to see family physicians.

Caring for children benefits family physicians and their patients. In an article in the September/October issue of FPM, Drs. Sumana Reddy and Jaydeep Mahasamudram observed that "the satisfaction that comes from taking care of children shouldn't be underestimated in a time of increasing physician burnout." Not only can family physicians smooth young patients' transitions from child to adult care, but by caring for parents and grandparents, they gain perspectives on inter-generational social interactions that pediatricians don't. One example: "As family physicians, we can see all of the ill members together, we can care for both the newborn and the breastfeeding mother with postpartum depression, and we can understand the teenager's mood disorder because we know the parents have been dealing with severe stressors even if the teen doesn't disclose this."

So how can family physicians counter national trends and provide care to more children? In addition to the strategies already mentioned, Drs. Reddy and Mahasamudram suggested taking advantage of opportunities to refresh one's knowledge on child-specific issues (e.g., Kawasaki disease); asking local internists and obstetricians for referrals; volunteering to give community talks on child health topics; and becoming more familiar with Current Procedural Terminology (CPT) codes for visits with young patients, especially those for vaccine administration.

Incidentally, my personal doctor is a family physician, and my wife and children all see a longtime family physician colleague of mine for primary care. Although primary care should stick together to provide a counterweight to the subspecialist-oriented U.S. health system, I also think that it's important for the future of our specialty that patients don't perceive family physicians to simply be another flavor of general internists.


A slightly different version of this post first appeared on the AFP Community Blog.

Thursday, October 31, 2019

Heading to the 2019 FMEC Annual Meeting

The Family Medicine Education Consortium (FMEC) is a major family medicine organization in the Northeast U.S. that serves as a "catalyst, convener, [and] incubator" for initiatives and programs in medical education, primary care, and community health. I first presented at their annual meeting in 2006, when it was still known as the Society of Teachers of Family Medicine Northeast Region meeting. I continued to attend regularly through 2011, when I, my wife, and our then-three children (one in utero) were involved in a major traffic accident on the Massachusetts Turnpike that ended up totaling our car and damaging six other vehicles. My older son sustained a scalp laceration from shattered window glass, and the rest of us were psychologically traumatized for varying lengths of time. Whether because I from then on associated this meeting with the accident or it was just easier to be the parent who stayed home with the kids while my wife traveled, I haven't been to an FMEC Annual meeting since, other than in 2014 when it was held in nearby northern Virginia.

That changes tomorrow at the FMEC's 2019 Annual Meeting.

Although I originally meant to deliver only a single presentation on a research paper I've been fortunate enough to work on with colleagues at Georgetown, Virginia Commonwealth University, Thibodaux Regional Medical Center in Louisiana, and the Lown Institute, somehow I've ended up having four. In addition to discussing our estimate of annual serious harms from overuse of screening colonoscopy in the U.S. (which number in the thousands to tens of thousands), I'm joining my wife and our family doctor to give a short lecture/discussion on when the doctor's child has a rare disease - in this case, Henoch-Schonlein Purpura, which afflicted our younger son last year around Christmas but fortunately resolved without any complications.

I was also invited by FMEC CEO Larry Bauer to co-lead a seminar on gun violence as a public health issue, a topic I've written about previously on this blog and in American Family Physician, but about which I'm certainly no expert. When I asked Larry why he thought I was best suited to present the evidence on this emotionally charged issue, he said that he was looking for someone who is respected across the political spectrum and perceived as being fair to all points of view. Larry, I promise I'll do my best.

Finally, Dr. Andrea Anderson, a longtime friend and DC-area colleague, asked me to join her in an Advocacy 101 workshop, where I will present tips on using blogs and social media to achieve one's advocacy goals. We will be joined by Dr. Joe Gravel, who will review the new Accreditation Council for Graduate Medical Education (ACGME) milestones for advocacy in family medicine training.

So it promises to be a whirlwind couple of days in Lancaster, Pennsylvania, the town where I grew from a freshly minted M.D. into a full-fledged family physician, and of course, where I met the love of my life. I'm looking forward to coming back.