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08/12/2019

What About the Drug Shortage Problem? (August 12th)

This past Friday, August 9th, STAT published my essay titled, "Presidential Candidates Aren't Talking About the Drug Shortage.  They Should Be."   

For all the discussion/effort this Congress concerning drug policy reform, moreover regarding excessive pricing there is none about worsening drug shortages (generally an under pricing problem)  - and the related quality problem in the generic drug manufacturing sector.  On the latter, see my July 17th interview with Katherine Eban concerning her recent, Bottle of Lies.  Nor are any of the presidential candidates, at least to date, discussing.  

The essay is at: https://www.statnews.com/2019/08/09/drug-shortages-presidential-candidates-policy/.

 

08/08/2019

Three Upcoming Podcasts In August and September

On Wednesday, August 28th, I'll speak with Philip Alston, UN Special Rapporteur on Extreme Poverty and Human Rights (and NYU Law School Professor) concerning his recently released report titled, "Climate Change and Poverty."  The summary of the report begins with, "Climate change will have a devastating consequences for people in poverty.  Even under the best case scenario, hundreds of millions will face food insecurity, forced migration, disease and death." Alston's report is at: https://chrgj.org/wp-content/uploads/2019/06/UNSR-Poverty-Climate-Change-A_HRC_41_39.pdf. Listeners may recall my summary of his May 2018 “Report of the Special Rapporteur On Extreme Poverty and Human Rights on His Mission to the United States," it is at: https://thehealthcareblog.com/blog/2018/08/22/the-uns-extreme-poverty-report-further-evidence-us-healthcare-is-divorced-from-reality/.

In late August I'll also speak with Dr. Lewis Cohen, Professor of Psychiatry at the University of Massachusetts-Baystate School of Medicine regarding his just published book, A Dignified Ending, Taking Control Over How We Die.

In early September I'll speak with Michael Chernew, Leonard D. Schaeffer Professor of Health Care Policy and Director, Healthcare Markets and Regulation Lab, at the Harvard Medical School, concerning the administration's efforts to make hospital cost data more transparent.  

 

07/25/2019

Dr. Georges Benjamin Discusses the Climate Crisis and APHA's Center for Climate and Health (July 24th)

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The news is grim.  Our planet has just experienced its hottest June in recorded history and likely the hottest July.  This year will likely join ten others since 2000 as the warmest ever recorded.  Several studies just published in Nature and Nature Geoscience have concluded there has never been a period over the past 2,000 years when temperatures have changed as fast and extensive as in recent decades.  To make matters worse, the climate crisis substantially explains the fact our planet is currently experiencing its 6th mass extinction – 4 of the previous 5 were also caused by high atmospheric CO2 concentrations, the worst of these extinguished 90% of all planetary life.  Despite the increasingly dire evidence, the federal leaders continue to do nothing.  The White House and the Republican Party not only refuse to admit reality but argue Americans have no fundamental right to a climate system capable of sustaining human life.  Congressional House Democrats refuse to move any meaningful legislation - even if that means simply putting Republicans on record for opposing maintaining life on earth and the health care industry, in sum, is neither working to reduce its own carbon emissions nor lobbying for requisite federal policy reforms.  Listeners may be aware this is my 8th climate crisis-related interview since last October.

During this 29 minute conversation Dr. Benjamin assesses the current stay of play relative to federal action concerning the climate crisis, he discusses the challenges the climate crises poses relative to achieving health equity and moreover the work of APHA's Center for Climate, Health and Equity (and how individuals can become involved in the APHA's climate crisis work). 

Dr. Georges Benjamin has served as Executive Director of the American Public Health Association since 2002.  He also serves as publisher of APHA's nonprofit's monthly publication, The Nation's Health, the association's official newspaper, and the American Journal of Public Health. Previously, Dr. Benjamin served as Secretary and Deputy Secretary of the Maryland DownloadDepartment of Health.  Dr. Benjamin began his medical career in 1981 in Washington State where he served as Chief of the Acute Illness Clinic at the Madigan Army Medical Center.  He subsequently moved to Washington, D.C. to serve as Chief of Emergency Medicine at the Walter Reed Army Medical Center.  After leaving the Army, Dr. Benjamin chaired the Department of Community Health and Ambulatory Care at the District of Columbia General Hospital, was promoted to Acting Commissioner for Public Health for the District of Columbia and later served as Interim Director of the Emergency Ambulance Bureau of the District of Columbia Fire Department.  He is the author of more than 100 scientific articles and book chapters.  His most recent book is, The Quest for Health Reform: A Satirical History is an exposé of the nearly 100-year quest to ensure quality affordable health coverage for all through the use of political cartoons.  Dr. Benjamin is a member of the National Academy of Medicine of the National Academies of Science, Engineering and Medicine and also serves on the boards for several organizations including Research!America and the Reagan-Udall Foundation.  In April 2016, President Obama appointed Dr. Benjamin to the National Infrastructure Advisory Council.  Dr. Benjamin is a graduate of the Illinois Institute of Technology and the University of Illinois College of Medicine.  He is board-certified in internal medicine and a Fellow of the American College of Physicians, a Fellow of the National Academy of Public Administration, a Fellow Emeritus of the American College of Emergency Physicians and an Honorary Fellow of the Royal Society of Public Health.

For information on the APHA's Center on Climate go to: https://apha.org/topics-and-issues/climate-change/center  
 
The APHA's 2016 "Climate Change and Health Strategic Plan" (noted during this interview) is at: https://www.apha.org/-/media/files/pdf/topics/climate/apha_climate_change_strategic_plan.ashx?la=en&hash=03D148BBD2A45E2A2B98BC4C98D33F32118244E1 
 
Phillip Alston's (United Nations' Special Rapporteur on Extreme Poverty and Human Rights) report, "Poverty and Climate" (also noted or quoted during this interview - and must reading) is at: http://www.guninetwork.org/files/unsr-poverty-climate-change-a_hrc_41_39.pdf

 

07/21/2019

Dr. Mark Fendrick Discusses Value-Based Insurance Designs (July 19th)

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One way to increase the value of insurance coverage is to eliminate or lower a patient's out of pocket costs (OOP), i.e., their co-pays and/or deductables, for health care services that are of high value, for example, vaccines and/or alternatively increase OOP costs for low value service, for example, certain imaging tests.  The concept is based on the straight forward rationale that, based on clinical evidence, certain health care products or services are proven to be more effective than others.  (This is the rationale for the Choosing Wisely program, at: https://www.choosingwisely.org/.)  OOP costs therefore should not be uniform for all services and medications, particularly when non-adherence rises along with rising health care OOP spending.  This largely explains the problem of medication non-adherence.  Phrased another way, we need need to solve for the increasing problem of under consuming high value care.  This idea was recognized in the 2010 Affordable Care Act, specifically Section 2713 [c] that eliminates patient cost sharing for specific preventive care services.  For example, OOP costs for significantly under-utilized breast and colorectal screenings, for which approximately only 72% and 60% of patients, respectively, are screened.  The value-based idea was furthered by the ACA-created CMS Innovation Center that in 2017 the launch the MA VBID demonstration - that was recently extended to 2024.  (This discussion is related to or can serve as a follow up to my May 11th conversation with Professor Andrew Ryan concerning measuring for value or spending efficiency.)

During this approximately 30 minute conversation, Dr. Fendrick discusses moreover the creation of the University of Michigan's VBID Center, provides his assessment of the current CMS Medicare Advantage VBID demonstration, the U. of MI Center's just announced V-BID X insurance design, VBID efforts at the state level and the Treasury Department's just-announced guidance allowing Health Savings Account/High Deductible Health Plans to practice VBID.   

Dr. A. Mark Fendrick is the Director of the Value-Based Insurance Design Center at the University of Michigan.  He is also Professor of Internal Medicine in the School of Medicine Amfenand a Professor of Health Management and Policy in the School of Public Health at the University of Michigan.  He has authored over 250 articles and book chapters and has received numerous awards for the creation and implementation of value-based insurance design.  Dr. Fendrick is an elected member of the National Academy of Medicine (formerly the Institute of Medicine or IOM), serves on the Medicare Coverage Advisory Committee, and has been invited to present testimony before the U.S. Senate Committee on Health, Education, Labor and Pensions, the U.S. House of Representatives Ways and Means Subcommittee on Health, and the U.S. Senate Committee on Armed Services Subcommittee on Personnel.  Dr. Fendrick is the co-editor in chief of the American Journal of Managed Care and is an editorial board member for three additional peer-reviewed publications.  He is also a member of the Institute for Healthcare Policy and Innovation at the University of Michigan, where he remains clinically active in the practice of general internal medicine.  Dr. Fendrick received a bachelor’s degree in economics and chemistry from the University of Pennsylvania and his medical degree from Harvard Medical School.  He completed his residency in internal medicine at the University of Pennsylvania where he was a fellow in the Robert Wood Johnson Foundation Clinical Scholars Program.

For information about U. of Michigan's Center for Value-Based Insurance Design to go: https://ihpi.umich.edu/center-value-based-insurance-design-v-bid.

A summary of the V-BID X proposal is at: https://www.healthaffairs.org/do/10.1377/hblog20190714.437267/full/.  The more complete white paper is at: http://vbidcenter.org/wp-content/uploads/2019/07/VBID-X-Final-Report_White-Paper-7.13.19.pdf.  

For information concerning Dr. Fendrick's mention of the just-released US Treasury guidance allowing HSA-HDHP plans the flexibility to cover specified medications and services prior to meeting the plan deductible go to: https://ihpi.umich.edu/center-value-based-insurance-design-v-bid

07/18/2019

Katherine Eban Discusses Her Just-Published Work, "Bottle of Lies, The Inside Story of the Generic Drug Boom" (July 17th)

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Nine in 10 prescriptions are today filled using a generic drug saving Americans tens of billions annually.   A significant amount of generic drugs, along with active ingredients in all drugs, are manufactured overseas.  However, how safely or to what quality standards are these ingredients and generics produced?   Bottle of Lies, published in May, tells the story of appalling practices foreign generic manufacturers use to produce these drugs at the most minimal cost.  The work moreover provides a detailed account of Ranbaxy, the former India-based generic manufacturer that after eight years of investigation was fined a then record amount,$500 million, for significant fraud.  The work questions or brings to serious doubt the FDA's ability to adequately inspect overseas generic manufacturers ensuring these drugs are safe for consumption in the US or around the world.  Listeners may recall I interviewed coauthor Paul Weinberg in September 2017 concerning his related work, Blood On Their Hands, How Greedy Companies, Inept Bureaucracy and Bad Science Killed Thousands of Hemophiliacs and Rosemary Gibson this past December concerning her related, China Rx, Exposing the Risk of America’s Dependence on China for Medicine

During this 37 minute interview. Ms. Eban provides an overview of Ranbaxy's manufacturing practices revealed by former employee and whistleblower, Dinesh Thakur.  She explains the mindset, termed "Jugaad," used in India to produce generics.  She discusses the adequacy of the 2013 US settlement with Ranbaxy , the role the Japanese firm, Daiichi Sankyo, a  major Ranbaxy stakeholder, the FDA's ability to adequately inspect Ranbaxy and other generic manufacturers around the world, e.g., Cipla and Mylan, recent and future related Congressional action, how poor or inadequate manufacturing practices complicate remedying the drug shortage problem and what precautions consumers or patients can take before consuming generic drugs.  

Katherine Eban, an investigative journalist, is a Fortune magazine contributor and Andrew Carnegie fellow. Her articles on pharmaceutical counterfeiting, gun trafficking, and 1811011_HS_114_RTcoercive interrogations by the CIA, have won international attention and numerous awards.  She has also written for Vanity Fair, The New York Times, Self, The Nation, the New York Observer and other publications. Her work has been featured on 60 Minutes, Nightline, NPR, and other national news programs.  She lectures frequently on the topic of pharmaceutical integrity.  Her first book, Dangerous Doses: a True Story of Cops, Counterfeiters and the Contamination of America’s Drug Supply, was named one of the Best Books of 2005 by Kirkus Reviews and was a Barnes&Noble Discover Great New Writers pick.  Her account of reporting on 9/11 was anthologized in At Ground Zero: 25 Stories From Young Reporters Who Were There. Her work has also been awarded grants from the Alfred P. Sloan Foundation, the Fund for Investigative Journalism, the Alicia Patterson Foundation and the McGraw Center for Business Journalism at CUNY’s Craig Newmark Graduate School of Journalism.  Educated at Brown University and Oxford, where she was a Rhodes Scholar.   

Information on Bottle of Lies is at: https://www.harpercollins.com/9780062338785/bottle-of-lies/.  

Ms. Eban's FAQ regarding how to learn about generics or best to consume is at: https://www.katherineeban.com/faqs

07/03/2019

"Can Medicine Be Cured?" (July 3rd)

Though I've been asked over the years to recommend readings I've avoided beyond noting those related to podcast interviews.   However, this work and lengthy review may be worth particular notice.  The book is Seamus O'Mahony's Can Medicine Be Cured? The Corruption of a Profession and the June review appearing in the Dublin Review of Books by Paul O'Mahoney is titled, "Made To Measure?"

At: http://headofzeus.com/books/can-medicine-be-cured

At: http://www.drb.ie/essays/made-to-measure-

06/20/2019

Brady President, Kris Brown, Discusses Current Policy Efforts to Curb Gun Violence (June 23rd)

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US gun violence is, in one word, obscene.  It is widely considered an epidemic, even the always cautious AMA termed it a "public health crisis" in 2016.  Through the first five months of this year there were 148 mass shootings that killed or wounded nearly 750 individuals.   It is worth repeating comments I made in April 2018 to introduce Dr. Al-Abga (whom treated victims of the 1999 Columbine High School shooting).  US gun deaths are 96 times higher than in Japan, 55 times higher than in the UK, 32 times higher than in Germany.  Gun violence is particularly common in schools.  Since 2000 there have been over 200 shootings in over 40 states at elementary, middle, high schools and at colleges and universities. Research suggests gun violence is explained largely by one fact: gun prevalence. The US makes up less than 5% of the world's population but owns nearly 45 percent the world's guns, or 300 million that one-third of Americans’ possess.  Ownership is, for example, 150 times higher than in Japan.  This fact largely explains why guns used to commit homicides far exceeds other developed countries.  US gun homicides are 471 times more prevalent than in the UK.  As for whether mental health issues explain US gun violence, the rate of severe mental disorders in the US is no greater than in comparative countries. 

During this 26 minute conversation Ms. Brown discusses Brady United's mission or work activities including its legal efforts relative to the 2nd amendment.  Moreover, she explains current efforts in the Congress to appropriate moneys for federal gun violence research (that has not been conducted for over 20 years) and recently House-passed bills that include regulating gun sales via extending background checks to private fire arm sales.  Ms. Brown also discusses policy plans by Democratic presidential candidates including Sen. Cory Borker to curb gun violence and she discusses the State of Virginia's upcoming special session next month in the wake of the May 31st Virginia Beach shooting that left 12 dead.  

Ms. Kris Brown is the President of Brady.  Ms. Brown began her career working on Capitol Hill for (now former ) Rep. Jim Moran (D-VA), advocating for the bill that would eventually KrisBrown-LipstickLobbyHeadshot_190225_192444become the Brady Act requiring background checks on federally licensed gun sales.  At Brady, she led the lunch of the organization’s safe storage campaign to End Family Fire and formed Brady’s “Team Enough” youth initiative after February 2018 Marjory Stoneman Douglas High School massacre in Florida.  A noted media commentator, Ms. Brown was, for example, featured in the November 2018 TIME magazine cover article titled, “Guns in America.”  Ms. Brown has also served as the Chief Legal Officer to a publicly traded company based in Switzerland and as a lawyer practicing at the law firm Weil, Gotshal & Manges.  She earned her law degree at George Mason University. 

For more on Brady go to: https://www.bradyunited.org/  

For information on the Enhanced Background Checks Act of 2019 go to: https://www.congress.gov/bill/116th-congress/house-bill/1112/text 

The recent debate sparked by FiveThirtyEight regarding the accuracy of CDC's gun injury statistics and titled, "The CDC is Publishing Unreliable Date on Gun Injuries, People Are Using It Anyway," is at: https://fivethirtyeight.com/features/the-cdc-is-publishing-unreliable-data-on-gun-injuries-people-are-using-it-anyway/

06/19/2019

Dr. Renee Salas Discusses Global Warming's Health Effects On Children (June 18th)

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This past June 4th the 9th Circuit Court heard oral arguments concerning Juliana v. the US, a case filed in 2015 by 21 children seeking a jury verdict on whether the US government, by failing to address the climate crisis, is protecting the plaintiff’s rights to life, liberty and the pursuit of happiness.  In its defense the US is arguing these children, now young adults, have “no fundamental constitutional right” to a “climate system capable of sustaining human life.”  In a May 30th essay published in The New England Journal of Medicine Dr. Salas and two colleagues agreed with the plaintiffs concluding , “As the Juliana plaintiffs argue - and we agree - climate change is the greatest public health emergency in our time and is particularly harmful to fetuses, infants, children and adolescent.” (Listeners may be aware this is my 7th climate crisis related interview since October.)

During this 26 minute interview Dr. Salas discusses her related research work, the amicus brief she and her colleagues forwarded in support of Juliana plaintiffs and other related litigation filed world wide.  Moreover, Dr. Salas explains the numerous adverse health effects children are suffering via the climate crisis including various birth defects, heart, lung and neurodevelopment illnesses, vector-borne diseases, harms from high heat and wildfire exposure, cognitive, behavioral and mental health effects, contaminated water, and numerous others.  She discusses what parents need to know or can do to protect their children and the extent the health care industry needs to (better) address its own contribution to greenhouse gas emissions/pollution or global warming. 

Dr. Renee Salas is Affiliated Faculty and a Burke Fellow at the Harvard Global Health Institute.   Her research addresses how climate change is impacting the healthcare system and developing evidence-based adaptation.She is also a practicing physician in the Department of Emergency Medicine at Massachusetts General Hospital and on faculty at Harvard Medical School.  Dr. Salas served as the lead author on the 2018 Lancet Countdown on Health and Climate Change U.S. Salas - HeadshotBrief and will again in 2019.   She lectures on climate and health nationally and internationally, has published in numerous scholarly journals and is the founder and past Chair of the Climate Change and Health Interest Group at the Society of Academic Emergency Medicine.  Dr. Salas received her Doctor of Medicine from the Cleveland Clinic Lerner College of Medicine with a Master of Science in Clinical Research from the Case Western Reserve University School of Medicine.  She also holds a Master of Public Health from the Harvard T.H. Chan School of Public Health with a concentration in environmental health.

Renee Salas, Wendy Jacobs and Frederica Perera's New England Journal of Medicine essay, "The Case of Juliana v US - Children and the Health Burdens of Climate Change," is at: https://www.nejm.org/doi/full/10.1056/NEJMp1905504 

The video of the 9th Circuit Juliana v the US oral argument is at: https://www.ca9.uscourts.gov/media/view_video.php?pk_vid=0000015741&fbclid=IwAR3K3vnHCO4M2KlcMZ1NSQ4ua1ZZhpdyA-hONwyj6N7uS0u1X5ojmuVVkCc

The amicus brief filed in support of the Juliana plaintiffs by 13 medical societies and over 65 medical professionals is at: http://clinics.law.harvard.edu/environment/files/2019/03/Juliana-Public-Health-Experts-Brief-with-Paper-Copy-Certificate.pdf

Again, my related essay, "Can the Climate Crisis Continue to Go Begging?" is at: https://www.3quarksdaily.com/3quarksdaily/2019/06/can-the-climate-crisis-continue-to-go-begging.html.

06/12/2019

175th Interview: University of Michigan's Professor Andrew Ryan Discusses Measuring for Spending Efficiency or Value in Healthcare (June 11th)

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Americans spend over $3.5 trillion or 6% of the GDP annually on health care.  One third, or over $1 trillion, of that spending is considered waste, i.e., health care that does not improve our health status.  Despite substantial efforts to improve health care value or spending efficiency via so called pay for value, performance based and alternative payment models, for example ACOs and bundled payment arrangements, health care providers, Medicare and other payers, do not generally measure for value - defined as outcomes (the numerator) achieved relative to spending (the denominator).   For example, the MACRA MIPS  program, that reimburses Medicare physicians, measures quality and spending separately, not simultaneously.  They are not correlated.  As a solution the government has been over the past few years advocating increasingly health care price transparency, specifically here price transparency.  If prices were transparent patients, less those riding in an ambulance, could shop for value. The problem is even if patients could intelligently shop for value, a big if, they would not get far because prices do not necessarily reflect value.  As I note in my Bloomberg Law essay posted as a run up to this interview, former Princeton economist, Uwe Rinehardt, use to explain this reality, or the fact that the same health care service can dramatically vary in price between/among provides, via the quip, "the finest health care in the world costs twice as much as the finest health care in the world."    

During this 28 minute conversation Prof. Ryan outlines his research interests, provides background on how measuring for quality, cost and spending efficiency has evolved, explains various methods of how spending efficiency is currently being measured (e.g., conditional and unconditional), to what extent pay for value or pay for performance arrangements have proven successful to date, what value-based payment models likely offer the most promise and what the patient can or should know about pay for value arrangements.  

Professor Andrew Ryan is United Healthcare Professor of Healthcare management and Professor or Health Management and Policy at the University of Michigan, Ann Arbor.  AmryanProfessor is also the Director of the Center for Evaluating Health Reform, the co-Director of the Center for Health Outcomes and Policy and the Associate Director of the Institute for Healthcare Policy and Innovation’s Data and Methods Hub.  Prior to coming to Michigan, Professor Ryan was an Associate Professor of Public Health in the Division of Outcomes and Effectiveness Research at Weill Cornell Medical College.  Among other awards he is the recipient of the 2009 AcademyHealth Dissertation Award for "The Design of Value Based Purchasing in Medicare: Theory and Empirical Evidence."  Professor Ryan earned his Ph.D. in social policy with a concentration in health policy from the Heller School of Social Policy and Management at Brandeis University. 

Professor Ryan's publications can be found at: https://sph.umich.edu/faculty-profiles/ryan-andrew.html.

The Bloomberg Law essay is again at: https://news.bloomberglaw.com/health-law-and-business/insight-containing-health-costs-requires-measuring-rewarding-spending-efficiency.

05/28/2019

Essay: "Containing Health Costs Requires Measuring, Rewarding Spending Efficiency" (May 27th)

Today, Bloomberg Law posted this essay in which I argue if Senator Lamar Alexander, Chair, HELP Committee, wants to address cost containment he needs address how we can drive greater spending efficiency or value in health care.  The essay is at: https://news.bloomberglaw.com/health-law-and-business/insight-containing-health-costs-requires-measuring-rewarding-spending-efficiency

Last Thursday, May 23rd, Senator Alexander released a draft list of provisions the HELP Committee is considering to contain costs or reduce spending growth.  The list is at: https://www.help.senate.gov/chair/newsroom/press/senate-health-committee-leaders-release-bipartisan-discussion-draft-legislation-to-reduce-health-care-costs

On June 11th I'll interview U. of Michigan Professor, Andrew Ryan, who has written several articles regarding measuring for value or again spending efficiency.  For example, see: https://journals.sagepub.com/doi/abs/10.1177/1077558716650089?journalCode=mcrd