MCN | Medical Consultants Network

The Power of a Second Look

Home / MCNTalk / Tag: Government Policy

Viewing items tagged:

Government Policy

Vaccinations: The Soaring Price of Prevention

MCNTalk has long taken on the vaccination story and has advocated rational and life saving public health policies that promote vaccination.

As this article demonstrates, the dark side of vaccinations is not the overstated risk of side effects, but the predatory cost escalation. The short answer to why the manufacturers are driving up prices is because they can.

This is further enabled by the requirements that some vaccinations be administered for school admission and other public good.

Also the lack of marketplace pressures since the cost is generally borne by government and insurance carriers promotes insensitivity and indifference among those who benefit from them. Finally, monopolies granted via patents and regulations do nothing to induce competition among manufacturers.

Politicians’ Prescriptions for Marijuana Defy Doctors and Data

Brian L. Grant MD

This is a fascinating article on a number of levels. The comments by readers as well as the article are illuminating. I come to it as a person who came of age in the 70s, trained in psychiatry and reside in Washington State. I also have an interest in medical anthropology which among other issues looks at cross-cultural health care systems and beliefs. Finally, I have a strong interest in medical politics and economics which are major drivers of policy and practice in US Healthcare.

Washington State is one where medical marijuana (cannabis) is legal and recreational marijuana will be legal in July with a rigorous permitting and taxation system. In observing the medical marijuana “industry” and practice in Washington, what has been clear is that it is a parallel system whereby anyone can obtain a prescription for medical marijuana and that a tiny minority have the sorts of diagnoses such as glaucoma, terminal pain, cancer, and the like that were invoked to justify medical marijuana in the first place. Furthermore, given the wide array of symptoms that may be “helped” by medical marijuana, most of which are subjective, such as pain and anxiety – there is not a person reading this post who could not receive authorization if they so choose. The dispensaries that provide pot use nice euphemisms such as “medicine” to describe cannabis, and “donations” as what one pays to receive their medicine. Whether one can obtain marijuana while declining a donation is not clear.

So in my view, medical marijuana at least in principle, if not in practice, is by and large a sham. It makes liars out of decent people who want to get high, have a good time, harm nobody in most cases, and perhaps relieve some real symptoms. Similarly, it promotes disingenuous behavior on the part of practitioners who prescribe it, some of whom are true believers, but all of whom are paid good money to write a script often based upon one visit with someone they will never see again.

Therefore, with reasonable reservations and concerns, one should be pleased to see marijuana become legal for recreational use. Like alcohol, which was touted during prohibition as having medicinal value as a way to access whiskey and other drinks  and more, read here and here), marijuana as a medical substance has by and large been a back door to access by those who want to smoke it for its mood altering attributes.

There are many similarities between alcohol and marijuana. Both are substances that can alter one’s thinking and are psychoactive. Both can be sources of enjoyment and conviviality and both can and do cause harm. One is by and large legal and the other not and therein lies the problem. If we as a society wish to ban all substances and behaviors with potential for harm, the list would be long, not end with alcohol, and would certainly start with tobacco and include excessive caloric consumption and other quite legal and common substances. Unlike alcohol, or increasingly prescribed opiates, marijuana has little propensity for physical addiction and tolerance.

Relatively speaking, the end organ damage and aggressive behaviors that excess or chronic use of alcohol induce significantly outweigh the degree of harm seen in typical marijuana users. The numbers of those who use alcohol abusively with resulting damage to themselves or others is significant. Since marijuana use is generally defined as abuse per se, studies looking at actual damage from the use of marijuana need to focus on objective rather than regulatory criteria. Is marijuana harmless? Of course not. Dosages are imprecise as one smokes something with inconsistent intake and varying amounts of active THC. “Edibles” can be misused or accidentally fall into the hands of children. One can simply lack balance and overuse marijuana in lieu of more productive and useful activities, just as could happen with alcohol consumption. And the impact of smoking marijuana is of unknown concern as at least one study suggests that lung damage from typical use is not an issue.

Neither cannabis nor alcohol belong in the hands or mouths of children and make no mistake – increased access to either creates some collateral damage that non-use would avoid, just like opiates or the 70 MPH speed limit on the highways.

Interesting systemic questions include: What is the role of the health care system in deciding that it owns a portion of the human experience, or that something is a medical issue rather than a component of general life? What are the economics of the system and the impact of a substance like marijuana that can be easily grown and distributed outside of the pharmaceutical industry with no inherent barriers to entry other than access to sun or artificial light, soil, fertilizer, water and seed stock? Could there be an element of those in power wanting to maintain control of an income stream, resulting in criminalization, and restrictive regulations along with false or distorted claims of harm to control distribution and access?

Finally, what damage has flowed from criminality of cannabis? How many have died as a result of criminal and gang drug traffic? How many harmless individuals have been prosecuted and jailed for use or distribution of marijuana? How many of the judges, prosecutors, and jurors sitting in judgment on these defendants can with a straight face deny their own use of cannabis in their own lives at some point? What can we learn from countries like Holland where cannabis has long been legal?

We are about to embark on an experiment in Washington state, already started in Colorado, with legal recreational marijuana. The ultimate results remain to be seen. Whatever one’s personal views on legalization of cannabis, facts and data should inform both personal and government decisions on the policies and use of cannabis and other products. Unfortunately the subject is often polarized by advocates and opponents.

Judge Upholds Policy Barring Unimmunized Students from School during Outbreaks

Brian L. Grant MD

MCNTalk has been following the vaccination refusal controversy for some time. As noted in this recent Times article, a NY court has affirmed the right to deny access to schools by unvaccinated children when another student is ill with a vaccine-preventable disease.

These particular cases are interesting because they illustrate a clash in values between sincerely held beliefs, religious or otherwise, and the public good. It leaves unanswered or at least unresolved the question of whether beliefs may trump good science. Also un-addressed is the practice in place whereby one can invoke religion where convenient, though scriptures are silent on vaccines and many other practices that individuals may choose to invoke religion to justify or excuse behaviors and choices.

Vaccines are a medical miracle that have virtually eliminated smallpox, diphtheria, measles, pertussis, and polio, maladies that have killed and maimed untold millions in the world and which can easily re-emerge when there is a sufficient number of unvaccinated to allow for transmission from person to person, versus current herd immunity that keeps the diseases in check.

Beyond the bad science claiming dangers of vaccinations are the polarizing effect of well-meaning parents and others who have come to believe these claims, clashing with other parents and authorities who do not want to support policies that in turn support the unvaccinated exposing their children and others to preventable risk.

The comments by readers, available along with the article, contain many compelling arguments worth considering on the topic.

How Health Plans Refusing Coverage Can Be of Benefit

by Brian L. Grant, MD

As noted in this New York Times article, more health plans are refusing to cover certain drugs unless the companies charge less for them.

Imagine a world in which food, housing, clothing, cars or other items we consume increased in price by 14% or more per year? What keeps this from happening in general is the pressure of the free market, responding to the pain that we feel every time we pull out our wallet to pay for something – motivating us to shop smartly, consider alternatives, and sometimes make a choice that is not what we would select if money were no object. How many of us work in companies where we can raise our prices by double digits annually, or see our pay increase by similar amounts year over year?

Not so in the world of specialty pharmaceuticals. We have been shielded from price by the impact of insurance payments and convinced that nothing but “the best” is good enough for us patients and that the insurance company writing the check (after our employers or government pay for the insurance), has no business exercising its economic power and “interfere” in what doctor thinks is best.

Nonsense! So long as we have abrogated payment to a third party, these third parties, be they government or commercial, have an obligation to introduce competition and create some pain and perhaps friction in the system. The days of patients paying for their own care are not likely to return. Kudos to the creative efforts to weigh cost and benefits, create formularies, and hopefully drive down some of the egregious pricing that appears to be in play.

Some drug companies choose to do end runs around co-pay requirements by giving rebates to patients, while still getting the big dollars from the carriers for the higher priced drugs. The move to escalate the fight by deleting certain drugs from formularies, forcing patients to pay the entire cost if they or their doctor refuse the alternatives, is a rational and needed escalation.

Veterans Administration Wait Lists — What Can We Learn from This?

Brian L. Grant MD

This editorial from the Seattle Times by Roger Stark raises a number of issues worth discussing. The recent controversy about the VA has been long in the making. It is about culture and corruption. But it also allows us an opportunity to look more closely at the fundamentals of the VA, ask tough questions and perhaps make some basic changes.

There is a lack of understanding about the VA and people tend to mix up and confuse issues. And the reverential manner with which it is spoken by most elected officials makes it difficult to have meaningful conversations.

My time in the VA is quite dated, going back to several rotations as a resident physician in the 70’s and 80’s. Back then I was struck by a number of observations:

  • Most admissions and patients were there for conditions that had nothing to do with military service. And a number of them were receiving permanent pensions because their conditions were identified in the course of service. Chronic Schizophrenia comes to mind. We now know that this is a biologic condition, not environmental, coincidentally becoming symptomatic in late adolescence and early adulthood when individuals may be in military service. If one lasted long enough in service, an early discharge and a lifetime of benefits would result, though the disease would have developed irrespective of service. Other medical admissions were often older Veterans with the usual maladies of age and lifestyle that one encounters in any hospital, such as heart and lung diseases, often flowing from lifestyle issues like tobacco use and diet.
  •  These hospitals were large institutions, often in the same vicinity as other facilities and clinics that offer excellent care options.
  • The staff were of high quality and some, like the Seattle VA, were teaching institutions affiliated with an excellent medical school, and helped train medical students and residents. They cared about their patients.

Setting aside the current controversy, we should ask several questions about the VA and where it should fit in the US Healthcare system:

  • What is the social contract between the VA and Veterans? Who should it serve and why? What is the distinction between those injured in the course of duty and those not? Should those who have served but have no injuries from their service be entitled to free health care via the VA system?
  • Does the current VA disability system work and when should an injury translate into economic benefits vs. treatment for the condition?
  •  What are the moral hazard and political implications of tying an injury to compensation? How does compensation muddy diagnoses like PTSD and traumatic brain injury?
  •  Assuming care is owed or committed, is a free-standing government run system the best way to accomplish this? What are the alternatives?

Readers of this blog know that the current healthcare system is not defended in terms of its economics. It is expensive and costs inflate far in excess of other countries with quality systems or the overall US economy. And there are inherent problems in a system where doing and procedures are rewarded while prevention and thinking is not. Furthermore the system is one where the patient is generally ignorant and disengaged on costs and treatment options and believes or acts as if the details and cost of care is an entitlement owed to them by their employer or government. This trend may be changing as cost sharing via copays and deductibles is growing under many policies. Most of us spend more time shopping for a TV set than a medical procedure or hospitalization that will cost 20-50 times as much or more, because with the TV and other personal expenditures, our interests lie in getting the best value for price.

Once we decide which Veterans to serve, could this not be better accomplished without a massive VA treatment bureaucracy? We have perfectly workable if imperfect government payment schemes including Medicare that can easily be ported to the VA and allow eligible Veterans to receive care from the facilities of their choice in the community.

Centers of excellence providing care for conditions unique to combat could be formed in partnership with high quality medical schools and research institutions for conditions such as amputations and combat-related PTSD.

Current VA resources and staff could be re-deployed into the private sector, where shortages exist presently and where demand would increase with Veterans entering the same system.

Is the current system inherently flawed and rather than focusing on current corruption, are bigger questions needing to be asked and answered?

What Childhood Asthma Treatment Rates Can Tell Us About Healthcare Reform

As this New York Times opinion piece notes, cost-sharing (e.g. co-payments and deductibles) is used to decrease health spending. Cost-sharing may be effective  in prompting people to think twice before seeking medical care or when selecting among options, but is it helping us reach the end goal of reducing the overall spend in the long run?

Treatment rates for childhood asthma are a particularly useful indicator, as having asthma inherently requires medical care, and preventive care is more effective and cost-efficient than treating someone during an attack. In other words, having to pay a large co-pay or deductible may discourage necessary treatment which only prolongs problems and makes them more expensive and more difficult to treat. A study just released in JAMA (Journal of the American Medical Association) Pediatrics indicates that poor families who have private insurance with higher cost-sharing are more likely to skip recommended care than those with lower cost-sharing or Medicaid. As the piece opinions:

In the United States, we have adopted a system where those who use the most care pay the most out of pocket. That may seem “fair” in some way, but cost-sharing isn’t about fairness. It’s about reducing health care spending without negatively affecting health outcomes. It should be a scalpel. We’re using it like a club.

Read more…

Will Transparency in Cost Help Force Competition?

Washington State lawmakers are hoping so – during the recent legislative session, they approved new transparency rules by January 2016. The belief is that transparency will force providers to be more competitive – cutting unnecessary spending such as ordering diagnostic tests which aren’t needed, or prescribing name brand drugs when generics work as effectively.

Washington’s largest insurance providers initially fought the proposal, objecting to disclosing their negotiated prices. So the database will contain only costs from Medicaid and insurance covering state employees, though supporters hope it eventually will be expanded. The Everett Clinic, north of Seattle, has so far posted prices for imaging services with the on-line encouragement for patients to call and ask for information on other services as well. Read more…

Narcotic Subsys Draws Attention

Last week we blogged about controversy over Zohydro, an opioid approved last fall by the FDA. Another narcotic, Subsys, is generating attention, as is maker Insys Therapeutics. Subsys, a form of fentanyl which is sprayed under the tongue, is a narcotic used when painkillers such as morphine aren’t effective. Subsys was approved by the FDA in 2012 to treat a small number of cancer patients. In the past year, sales of Insys Therapeutics have soared and its share price has jumped nearly 270 percent. Over the last week, however, shares of Insys have lost roughly a third of their value after the arrest on federal fraud charges of a Michigan neurologist who was a top prescriber of Subsys.

Concern over Subsys are centered around aggressive marketing practices and off-label uses (uses the drug was not originally intended for), as the drug was approved to relieve cancer patients but fewer than 1% of prescribers are oncologists. Read more…

Spotting Medicare Fraud

Medicare insures 49 million Americans a year, at a cost of about $604 billion annually – and spent another $1.5 billion fighting health-care fraud last year. But a loose system of investigators can’t reliably spot suspicious billing.

Medicare made public the details of $77 billion in payments to doctors, labs, ambulance companies, and other medical providers in an effort to increase transparency and get the public’s help identifying improper payments.Within days of the document dump, Bloomberg News, the New York Times, USA Today, and ProPublica, among others, did just that, uncovering tens of millions of dollars’ worth of questionable billing practices, as well as payments to doctors whose checkered records the federal government may not have been aware of. Read more…

Serious Concerns with New Prescription Pain Killer

The prescription pain-killer Zohydro (pure hydrocodone in an extended-release formulation) was approved last fall by the FDA against the advice of its own advisory panel. Given the number of people in the U.S. who live with chronic pain (estimated to be around 100 million, though the figure is disputed), and that about half the drug overdose deaths in the U.S. are from prescription painkillers, Zohydro’s launch has drawn its share of attention.

In March, Gov. Deval Patrick of Massachusetts sought to ban Zohydro outright, calling it “a potentially lethal narcotic painkiller,” and 29 state Attorneys General have asked the FDA to reconsider approval. A number of patients had to leave the clinical study because they had serious adverse side effects or didn’t comply with the terms of the trial. Fewer than 300 subjects made it through a full year in the long-term safety trial, and there were five deaths.

Members of the F.D.A. committee who voted against approval acknowledged they were influenced by the drug overdoses claiming more and more lives each year. But they were also disturbed by red flags raised during the clinical trials of Zohydro.

“You still have a 1 percent, almost, death rate from this drug,” said Dr. Jeanmarie Perrone, a committee member from the University of Pennsylvania. What will happen in the doctor’s office, she wondered, where those receiving the drug will not be as carefully screened?