Hospitals consolidation: Brill says yes, new Massachusetts AG says no

From Shirley Leung’s Monday column in the Globe:

partnersNo judge or jury delivered a verdict on the Partners HealthCare settlement Monday, but we didn’t need either after Attorney General Maura Healey’s three-page court filing.

She thinks the deal stinks, and if given the chance, she would bring an antitrust suit to block Partners’ efforts to expand. And just like that, the 43-year-old rising political star dared to rock the biggest boat in Massachusetts health care. In the wake of her threat, Healey left a list of winners and losers.

From Steven Syre’s column in today’s Globe:

Maura Healey has been on the job less than a week, but we don’t have to wonder where she stands on the biggest health care conflict in Massachusetts.

And, a Q. & A. from Steven Brill, author of “America’s Bitter Pill: Money, Politics, Backroom Deals and the Fight to Fix Our Broken Health System. That book looks at focuses on the debate over the Patient Protection and Affordable Care Act. But it also returns to Brill’s indictment of high hospitals costs that filled an entire issue Time magazine in 2013. His solution looks very much like a combination of the Kaiser Permanente insurer-plus-provider approach and the Partners’ plan.

HLM: Why will this consolidation approach work to curb costs where other reforms have failed?

Brill: The reason this idea may work is it is going to happen without my writing about it. It’s going to happen. The question is, do we seize that momentum, turn it around jujitsu- style and attach a whole bunch of regulations to it?

I really started thinking about this after my [heart] surgery. I decided: New York Presbyterian, it’s a damn good place and the guy who runs it is a good guy. [Later] I was watching a panel including Toby Cosgove [CEO of Cleveland Clinic] and someone said: You’re gobbling up Cleveland and your market share is way too high.

Cosgrove said, the FTC would never let us have too much of a market share. I’m thinking, this guy Cosgrove, he’s a celebrated surgeon, a war hero. He seems like a pretty good guy to me. The idea the he wants to control and provide healthcare all over Ohio, why is that such a bad thing?partners-logopartners-logo

Yale’s Dr. Ross and the promotion of me-too meds

From ProPublica on me-too meds. Yale’s Dr. Joseph Ross gets a quote in this story. , Vox offers a summary of his NEJM piece on digital marketing to docs. More here on his work into the accuracy of clinical trial registries.

Here’s the NEJM abstract: Pharmaceutical marketing can lead to overdiagnosis, overtreatment, and overuse of medications. Digital advertising creates new pathways for reaching physicians, allowing delivery of marketing messages at the point of care, when clinical decisions are being made.

From ProPublica

Vying for Market Share, Companies Heavily Promote 2018 Me Too’ Drugs

by Charles Ornstein and Ryann Grochowski Jones ProPublica, Jan. 7, 2015, 2 p.m.

propub logoThis story was co-published with the New York Times’ The Upshot.

For more than five decades, the blood thinner Coumadin was the only option for millions of patients at risk for life-threatening blood clots. But now, a furious battle is underway among the makers of three newer competitors for the prescription pads of doctors across the country.

The manufacturers of these drugs 2014 Pradaxa, Xarelto and Eliquis 2014 have been wooing physicians in part by paying for meals, promotional speeches, consulting gigs and educational gifts. In the last five months of 2013, the companies spent nearly $19.4 million on doctors and teaching hospitals, according to ProPublica’s analysis of federal data released last fall.

The information, from a database known as Open Payments, gives the first comprehensive look at how much money drug and device companies have spent working with doctors. What it shows is that the drugs most aggressively promoted to doctors typically aren’t cures or even big medical breakthroughs. Some are top sellers, but most are not.

Instead, they are newer drugs that manufacturers hope will gain a foothold, sometimes after failing to meet Wall Street’s early expectations.

“They may have some unique niche in the market, but they are fairly redundant with other therapies that are already available,” said Dr. Joseph Ross, an associate professor of medicine and public health at Yale University School of Medicine. “Many of these, you could call me-too drugs.”

In almost all cases, older, cheaper products are available to treat the same conditions. Companies typically try to differentiate the new drugs by claiming they are easier to use; carry fewer side effects; work faster than competitors; or have medical advantages.

The makers of Pradaxa, Xarelto and Eliquis, for example, say their drugs are at least as effective as Coumadin for certain conditions but do not require routine blood tests or limitations on what patients can eat. (Patients taking Coumadin, also known as warfarin, shouldn’t eat grapefruit or cranberries and have to limit green leafy vegetables in their diet.)

Officials at the Centers for Medicare and Medicaid Services, which administers Open Payments, and the Pharmaceutical Research and Manufacturers of America, the drug industry trade group, said they had not analyzed the data in order to rank spending by drug.

When told of ProPublica’s analysis, John Murphy, PhRMA’s assistant general counsel, said drug makers’ spending should be seen not only as a marketing strategy, but also as a way of ensuring the best treatment options for patients. “On paper, a drug may not look like it is monumentally better than another drug, but to an individual patient, it might be,” Mr. Murphy said.

* Note: General Payment figures do not include royalties. Source: Centers for Medicare and Medicaid Services, Food and Drug Administration, ProPublica reporting

According to ProPublica’s analysis, Victoza, a diabetes medication made by Novo Nordisk, was the drug associated with the most payments to doctors, by dollar amount. The company spent more than $9 million on physician interactions related to Victoza in the last five months of 2013, excluding research payments and royalties, which relate more to drug development than marketing. (ProPublica created a tool that lets you look up any drug, device or company and compare it with any other.)

Victoza, through a once-a-day injection, helps lower blood sugar among diabetics, but researchers and advocacy groups have said drugs of its class carry an increased risk of thyroid cancer and pancreatitis. Dr. Todd Hobbs, chief medical officer of Novo Nordisk in North America, said the company’s spending reflected Victoza’s newness and the need to address such safety concerns.

“We just received a huge amount of interest and questions and need for education,” Hobbs said, referring to inquiries by health care professionals, particularly primary care doctors. “You see the fruits of that in this report.”

Eliquis, the anticoagulant jointly marketed by Bristol-Myers Squibb and Pfizer, ranked second in its link to spending on physicians, with nearly $8 million, our analysis showed. In a statement, the companies said their spending helps ensure physicians understand the appropriate use of Eliquis. Because the drug is prescribed by physicians in different specialties, the statement said, “it is critical to have a speaker program that adequately provides robust education to these physicians.”

The drug associated with the third-most payments to doctors was Brilinta, a different type of blood thinner made by AstraZeneca that vies for sales with Plavix, which is now available generically. In an email, AstraZeneca said it had identified Brilinta as one of its “key platforms for growth” and increased speaker and research spending on it. “Physicians are also indispensable partners in our efforts to bring new medicines to patients,” the company said.

ProPublica has tracked drug companies’ payments to doctors since 2009 through a searchable database called Dollars for Docs. But this covers only 17 companies, most of which have been compelled to release this information under legal settlements with the government. It has no information from medical device makers.

The list of most promoted drugs featured many recent arrivals: 14 of the top 20 were approved by the Food and Drug Administration since 2010. Some treat similar conditions, including diabetes, schizophrenia and chronic obstructive pulmonary disease, so the competition among them is fierce. “They’re fighting over the same doctors, I guarantee you,” said Rhonda Greenapple Simoff, founder of a consulting firm that advises pharmaceutical companies in Bernardsville, N.J.

Largely absent from the top of the list were drugs that cure disease, such as a new class of hepatitis C treatments, or those that significantly extend life, particularly for cancer patients. If a drug is either the first to treat a disease or is much better than existing drugs, said Dr. Sidney Wolfe, the founder and now senior adviser to Public Citizen’s Health Research Group, “they ‘sell themselves’ on the merits of their unique benefits.”

According to ProPublica’s analysis, a few of the most heavily promoted drugs, including Samsca, which treats low sodium levels in the blood, have serious side effects that came to light after their approval by the federal government. The manufacturers of several others, including Copaxone, Latuda, Xarelto, Daliresp and Humira, have been faulted by the F.D.A. for improper promotion.

Subsys, approved in 2012 to treat cancer pain, ranked 23rd in spending on doctors. It’s often prescribed for off-label, or unapproved, uses; in November, The New York Times reported that some of the doctors paid the most to promote the drug had disciplinary or legal troubles. In a statement to The Times, Insys Therapeutics, the drug’s maker, said its marketing of Subsys was appropriate.

The medical device associated with the most payments to doctors was Intuitive Surgical’s da Vinci surgical robot system, which the company has marketed as an effective, less invasive option for an array of procedures. Critics have complained that the device is needlessly expensive and overused, and say it has been linked to patient complications and deaths.

Intuitive spent nearly $12.8 million on physician interactions to promote the robot in the last five months of 2013, not including royalties and research. The spokeswoman Paige Bischoff said in an email that about half of the company’s outlays for education and training were “pass through” spending: Surgeons or hospitals paid the company for services, and the company, in turn, paid doctors to provide them.

Dr. Robert Takla, an emergency room physician in the Detroit area, earned about $75,000 in the last five months of 2013 by delivering promotional talks about several of the most heavily marketed anticoagulants and blood thinners, particularly Brilinta, according to Open Payments.

He said he enjoys speaking on behalf of companies and thinks he offers a different perspective than cardiologists and internists 2014 the usual prescribers of the drugs 2014 because he treats complications of blood clots in the emergency room.

Dr. Takla said he reviews clinical studies before deciding to speak for a drug and turns companies down when he isn’t impressed. He said he no longer spoke on behalf of Pradaxa because of what he characterized as public backlash against it, driven by a spate of lawsuits against its manufacturer, Boehringer-Ingelheim. (The company agreed to pay $650 million last year to settle the suits.) He accepts fees to speak about Xarelto, a drug he has taken himself for a deep vein thrombosis.

“It’s a very fertile and very robust marketplace right now,” he said of the anticoagulants.

News applications developer Mike Tigas contributed to this report.

Methodology: How we calculated company payments to doctors

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Compare Massachusetts doctors via quality reports and patient feedback

CR MA. Doc Ratings Insert_300Searching for health care services on the Internet can be like searching info about food, hotels or pets. You have to sort through a lot of low quality or scraped sites that don’t offer much.

Healthcare Compass looks like a good destination for Bay Staters.

On this website, there are two different ways to compare doctors’ offices:

  • A survey of more than 40,000 patients across Massachusetts that collected details about the care they receive at their own doctors’ offices.
  • Reports that measure how well the doctors’ offices achieve nationally recognized standards for high-quality primary care…

This website helps patients answer two questions about their health care quality:

Are primary care doctors giving their patients the correct preventive care services (such as cancer screenings) and chronic disease care (such as asthma or diabetes care)? The Clinical Quality report looks at how this of care was given to patients at doctors’ offices.
Learn more about the Clinical Quality Report

 How are patients’ experiences with their doctor office? Does their doctor’s office know about them and the care that they should be receiving? The Patient Experience Survey is a statewide survey that asks patients to report about their experiences with a specific primary care doctor and with that doctor’s office. 

Learn more about the Patient Experience Survey report

 

Also, click here for a source of raw data: Patient HealthDecider 

 

Former Tufts doc: “Widespread dishonesty” leads to unjustified health care fees #HCR

Former Tufts doc and current Mainer Howard A.Corwin comments this weekend on the latest in Elizabeth’s Rosenthal’s great NYTimes series on insane health care costs. In her latest piece, she reports that “In operating rooms and on hospital wards across the country, physicians and other health providers typically help one another in patient care. But in an increasingly common practice that some medical experts call drive-by doctoring, assistants, consultants and other hospital employees are charging patients or their insurers hefty fees.”

To which Corwin notes: 

To the Editor:

Doctors call such billing “gaming the system.” There is widespread dishonesty that leads to these unjustified expenses throughout the medical profession. Members of Congress beholden to medical lobbyists allow flawed reimbursement systems and perpetuate them by preventing reform. There is an enormous disparity between what different medical specialists and personnel earn. Unable to rectify these disparities, many physicians resort to these gaming techniques. Unnecessary expensive tests and procedures, upgraded coding, “scratch my back and I’ll scratch yours” referrals and, of course, outright greed lead to extra medical expense.

Honest doctors are demoralized and suffer from this system. Doctors must regain leadership of medicine to rectify these aberrant and destructive practices.

HOWARD A. CORWIN
Center Lovell, Me., Sept. 21, 2014

The writer is a former clinical professor of psychiatry at Tufts University School of Medicine.

#NEJM #Relman obit: “A master in the use of the bully pulpit” #HCR

A not entirely objective perspective on the  career of the journal’s storied editor. Here’s the last paragraph:

In the increasingly complex world of health care, Bud Relman was a prophetic figure, larger than life. He acted nejmas our conscience. In his writing and speaking, he always reminded us that the medical profession is far more than a business and that as physicians, we have the responsibility to do what is right for patients and for the community as a whole. As distinguished as he was as a researcher, clinician, editor, teacher, and administrator, Bud Relman will be most remembered for the way he fought for a fundamental reshaping of our nation’s health care system. His passionate commitment to that cause will forever secure his position in the pantheon of leaders in medicine.

 

 

Video: How to use national database to evaluate your doctor’s Medicare billing, treament patterns #hcr #doctors #costs

More from ProPublica:

Medicare recently released, for the first time, details on 2012 payments to individual doctors and other health professionals serving the 46 million seniors and disabled in its Part B program. Part B covers services as varied as office visits, ambulance mileage, lab tests, and the doctor’s fee for open-heart surgery. Use this tool to find and compare providers. | Related story »

Investigative health reporting lives: Milking Medicare

The latest in health data reporting  from ProPublica:

downloadMedicare paid for more than 200 million office visits for established patients in 2012. Overall, health professionals classified only 4 percent as complex enough to command the most expensive rates. But 1,800 providers billed at the top level at least 90 percent of the time, a ProPublica analysis found. Experts question whether the charges are legitimate.

For more: Top Billing: Meet the Docs who Charge Medicare Top Dollar for Office Visits

For a more precise look at your own doc note:

Looking at raw numbers, though, can unfairly flag some doctors who have multiple providers billing under their IDs or who justifiably use expensive services. It can be more revealing to look at which procedures doctors are performing and how frequently, and how their billings compare with those of their peers. (ProPublica has created a tool called Treatment Tracker that allows users to do just that.)

More health reporting from the ProPublica archives:

More than 1 million patients suffer harm each year while being treated in the U.S. health care system. Even more receive substandard care or costly overtreatment. Our ongoing investigation of patient safety features in-depth reporting, discussion and tools for patients.

Never-before-released government prescription records shows that some doctors and other health professionals across the country prescribe large quantities of drugs known to be potentially harmful, disorienting or addictive for their patients. And officials have done little to detect or deter these hazardous prescribing patterns.

ProPublica is tracking the financial ties between doctors and medical companies.

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