On the Health Affairs blog, Kaiser Family Foundation president Drew Altman and Harvard's Bob Blendon say public opinion alone won't drive health care reform. Excerpts:
“What health needs most to rise up in American politics is for national political candidates, whether from the political left, right, or center, to begin talking about the issue again as they did in the early nineties. Most important of all are the presidential candidates, who receive so much national media attention. If even one major candidate begins to seriously address health reform, the others will be forced to follow suit. … If [candidates] do play a leadership role on health, the media will follow, and the agenda-setting power of a debate driven from the top will meet the public’s concerns rising up from the bottom like two weather fronts colliding. ...
We poll the public all the time, and we believe that it is unrealistic to expect public opinion, on its own, to reach some new tipping point that will create a tidal wave for health reform. For health to compete more effectively with other issues on the national agenda, it will take leadership in the form of visible political candidates willing to champion the issue, and the media attention that follows. Greater attention on the part of all interested in achieving change in American health care should be directed towards that goal, and towards developing policy proposals that can bridge the ideological divide and provide a basis for legislative action when health reform makes it back to the national agenda. Unless these things happen, we are unlikely to see major change in health care in the foreseeable future."
Business Week has an interesting special report on "blurring the lines between objective science and financial gain. "
The magazine profiles a New York heart specialist who is chairman of the Cardiovascular Research Foundation in New York. Excerpt: "The foundation uses donations and fees from medical device companies to stage (an) annual conference, called Transcatheter Cardiovascular Therapeutics (TCT). A professor of medicine at Columbia University, he has helped start a handful of cardiac device companies through a corporate "incubator" he co-founded. He also has served as a paid scientific adviser for several other startups. Over the years, companies to which he has had close ties have been featured prominently at TCT, creating at minimum a perception that the companies' products are favored for reasons other than medical merit. ... Beyond the danger that conflicts may distort individual clinical decisions, some TCT observers worry that the event engenders a general excess of enthusiasm for complicated device-based procedures. From 1986 to 2003 the number of nonsurgical cardiac procedures, such as propping open arteries with wire-mesh stents, rose twelvefold, according to the American Heart Assn. Such procedures "are uncomfortable, relatively expensive, and might be taking the focus away" from less invasive, equally effective treatments, such as taking medicine, says Dr. David D. Waters, chief of cardiology at San Francisco General Hospital."
Read the entire report. It paints a picture that is now being seen more often in medical research - a tangled web of conflicts of interest with big dollars at stake. And where, in all of this, are consumer interests represented?
Sometimes you see a letter to the editor of a newspaper that you just want to frame. One such note appeared in today's Star Tribune.
The letter stated:
"Why not a more accurate headline for your Oct. 23 Business article "Massage that offers a healing message"? I suggest "St. Thomas prof sees business opportunity in quack remedy."
Would the Star Tribune's "Small Business" feature have endorsed treating breast cancer by manipulating the patient's "energy"? Would a St. Thomas professor (mindful of that institution's business ethics program) have cited the fact that breast cancer patients are "very likely to take on alternative therapies" as a marketing advantage?
As an Asperger's parent, I'm tired of being treated as a sucker and cash cow for unproven remedies. When looking at possible medical treatments, businesspeople, writers, editors and "experts" owe the public the truth. If the "evidence" for effectiveness is just someone's personal story and there is no scientific rationale, it may be all right to study the treatment, but it is evil to commercialize it."
I recall reading the story in question (but was unable to find it now in the Star Tribune archives), and I recall my reaction was not far from this woman's reaction. But, as I've stated before, newspapers seem to have a different set of guidelines - and perhaps a different standard of ethics - for the Business section. There seems to be a lower standard of evidence if the story promotes any local product or company.
A team from the University of the Michigan and the VA question the National Institutes of Health guidelines that call for aggressive cholesterol lowering in people at high risk of, or who have already suffered, heart attacks and strokes. In a review in the October 2006 Annals of Internal Medicine, three researchers write that the "current clinical evidence does not support" the idea that aggressive statin therapy to achieve very low cholesterol levels for high-risk people "is beneficial or safe."
Of course, the guidelines in question are the ones for which eight out of nine guideline authors had financial ties to manufacturers of statin drugs.
The website, The Smoking Gun, reports that former NBC anchor Jane Pauley has sued the New York Times, claiming the paper duped her into granting an interview for what was really a drug-company advertising supplement.
The website reports: "In a lawsuit filed Tuesday in U.S. District Court, the 55-year-old broadcaster charges that she believed that the Times interview was for a news article on mental health issues, but that the story (accompanied by a full-page photo) ran in an October 2005 "special advertising supplement" promoting psychotherapeutic drugs sold by Eli Lilly and other pharmaceutical firms. Pauley, who in September 2004 disclosed her battle with bipolar disorder, alleges that the Times "duped" her into lending her name to its advertising gambit, according to the lawsuit. After going public about her bipolar disorder, the lawsuit notes, Pauley has worked with several mental health advocacy groups, including the National Mental Health Association. Pauley's lawsuit seeks unspecified damages from the newspaper and DeWitt Publishing, which helped arrange the advertorial."
Many Americans may not be aware that the nation's "transplant system," such as it is, is largely influenced by a private contractor to the federal government. The agency is called UNOS, the United Network for Organ Sharing.
Back in my reporting career - almost 20 years ago - I pointed out questions about UNOS and its managment of transplant issues.
Now the Los Angeles Times reports that UNOS is "lax in oversight" and "routinely fails to detect problems." The Times asserts that:
• UNOS has never recommended that the government close an active transplant program.
• Even after programs log high death rates, years sometimes pass before UNOS takes meaningful action.
• UNOS often backs down after being challenged — or even defied — by medical centers it is supposed to regulate.
• UNOS officials have missed obvious red flags, including troubling transplant center statistics available on its own website.
Read the entire article. More Americans should know more about UNOS and ask more questions.
A series of articles in Health Affairs address the question of whether high-deductible "consumer-driven health care" (CDHC) plans will keep consumers from seeking needed care.
Health Affairs also includes the following perspectives on the new studies.
Marjorie Ginsburg, executive director of Sacramento Healthcare Decisions. “It is not likely that CDHC will add to the serious debate that Americans must have to reach a just, efficient, and effective health care system,” Ginsburg says. “In the end, the big-picture questions about health care coverage will have to be asked and answered by many voices, not addressed through an individual’s personal treatment decisions. Regardless of a patient’s willingness to pay a high deductible, should health insurance cover a promising cancer drug costing $100,000 a year? Should insurance pay $1,500 for a scan to diagnose Alzheimer’s disease when no cure is available, or pay for extensive medical work-ups for adults without risk factors or symptoms?”
John Goodman, president of the National Center for Policy Analysis. Goodman argues that the authors ignore the fundamental fact that “health care has to be rationed.” He states, “Someone must choose between health care and other uses of money”; the answer given by CDHC is that the patient should choose. He notes that in cosmetic surgery, where consumerism governs, the typical patient can “(1) find a package price in advance covering all services and facilities, (2) compare prices prior to the surgery, and (3) pay a price that is lower in real terms than the price charged a decade ago.”
Peter Lee, CEO of the Pacific Business Group on Health, and Emma Hoo, PBGH director of value-based purchasing. Lee and Hoo say that CDHC “is only one component of a broader quality-based benefit design strategy” that is needed to promote better quality and hold down health care costs.
Tony Miller, managing director of Lemhi Ventures and cofounder of Definity Health says CDHC “is about a change in the way we are going to finance our consumption of health care services so that users of those services have more control over how the dollars are spent.” Miller criticizes the new papers for “pining for a past that never existed” in which “utopian conditions of quality and cost predated CDHC.”
Murray Ross, Kaiser Permanente director of health policy and research, suggests that disease management conducted through organized provider groups and delivery systems is more likely than higher premiums or deductibles are to effectively cut costs.
Consumer-driven plans have been pushed by the Bush administration as a health policy solution.
My friend Andrew Holtz asked journalists on the Association of Health Care Journalists' listserv, "Why did this week's Cochrane review examining the balance of risks and benefits of mammography get widespread coverage in the UK, but almost no mention in the US news media? Of the two dozen stories picked up in a Google News search, almost all were from the UK, Australia and other Commonwealth nations, but there were no U.S. news stories found. The story hasn't appeared on NYTimes.com, Washingtonpost.com or LATimes.com. CNN.com mentioned it only in its international section as part of a world news digest. So the BBC and others had headlines like: "Breast Screening Concerns Raised" and "Researchers question benefits of breast cancer screening." Meanwhile, US news outlets ran story after story on breast cancer that never mentioned the potential downsides of mammography... with rah-rah leads such as "Mammograms are good" and "No more excuses for not getting mammograms." It seems British and Australian editors have a different view from those in the US about what sort of info is relevant to their readers and viewers."
You can read the BBC story as an example of what you didn't get here. Excerpts:
"They found that for every 2,000 women screened over a decade, one will have her life prolonged, but 10 will have to undergo unnecessary treatment."
"...The scientists found mammograms did reduce the number of women dying from the disease. But they also discovered it was diagnosing woman with breast cancer who would have survived without treatment, meaning they were undergoing unnecessary chemotherapy, radiotherapy or mastectomies. About a fifth of cancers picked up by screening are in the milk ducts of the breast. Some of these cancers will progress while others will not - but there is no way of predicting what will happen. This means women and doctors have to decide whether or not to risk doing nothing, or go ahead with treatment which might be unnecessary. They also revealed a further 200 women out of every 2,000 experienced distress and anxiety because of false positives - a result that indicated a cancer was present but was later found to be wrong."
Some journalists responded on the listserv that the Cochrane Library review was just that - a review of past studies - and therefore, not news. Others responded with emotion - not evidence - about a woman's "need" to, or "right" to, have regular mammograms. (These were supposedly even-handed journalists, mind you.)
Holtz's observation about British and Australian editors having a different view from those in the US about what sort of info is relevant to their readers and viewers is interesting, and it may reflect an American cultural bias toward more screening and more aggressive treatment, regardless the evidence.
In his latest commentary from the National Institute of Health Policy, former U.S. Senator David Durenberger (R - Minn.), reacts to the management meltdown at UnitedHealth Group (UHG) that led to the ousting of CEO & chairman Bill McGuire:
"Minnesota journalists, asleep at the UHG switch while the Wall Street Journal and others did their work for them, are interesting in their reaction. What will happen to Twin Cities philanthropy? To the arts? The University of Minnesota? Would McGuire use his money to cover the uninsured? In our very best “Minnesota Nice” style, no one in MN but Attorney General Mike Hatch would even suggest the McGuires forego the financial gains from Bill’s bad judgment. Why risk Bill’s infamous temper if you’re hooked on “philanthropy?” Perhaps they’ve forgotten that the company foundation gave less than 10% of its gifts to Minnesota charities last year.
Minnesota’s donor/benefactor community knows what happened to the last Stanley Cup hockey winner in Minnesota when we criticized owner Norman Green for both his grating personality and mounting financial and legal problems. He quickly moved the North Stars to Dallas. This was about the same time United founder – and now new chairman - Rich Burke was buying the Winnipeg Jets and moving them right through Minnesota to Phoenix. And Minnesotans assume Texan McGuire can do the same. After all, we’re still a “small fish” market for folks who like to swim with sharks. And, as I mentioned a year ago, United directors actually believe the company would move its headquarters out of a state that won’t let them sell insurance products if the heat was turned up. So why not now?"
As if billion dollar health care industry issues aren't complicated enough, let's bring in "philanthropy" and big-league sports. Durenberger offers an interesting perspective.
Three doctors at the National Institutes of Health, in an article in this week's New England Journal of Medicine, criticize the Eli Lilly drug company for its promotion of the expensive sepsis drug Xigris.
The doctors claim that Lilly manipulated treatment guidelines to give Xigris the upper hand over older, cheaper and equally effective treatments.
The authors wrote: "To improve sales of (Xigris) in 2002, Lilly hired Belsito and Company, a public relations firm, to develop and help implement a three-pronged marketing strategy. First, the product's sales were to be supported by marketing initiatives targeted to physicians and the medical trade media. Second, because (Xigris) was relatively expensive, word would be spread that the drug was being rationed and physicians were being "systematically forced" to decide who would live and who would die. As part of this effort, Lilly provided a group of physicians and bioethicists with a $1.8 million grant to form the Values, Ethics, and Rationing in Critical Care (VERICC) Task Force, purportedly to address ethical issues raised by rationing in the intensive care unit. Finally, the Surviving Sepsis Campaign was established, in theory to raise awareness of severe sepsis and generate momentum toward the development of treatment guidelines."
Eventually the efforts of that ~$2 million task force led to treatment guidelines, as the New York Times reports, "that rated Xigris more highly than older treatments for which clinical trials treating sepsis had never been conducted."
The Times also reports that "Xigris, which costs about $8,000 for a four-day course of treatment, generated controversy even before federal regulators approved it in November 2001. To win approval, Lilly presented results from a clinical trial that showed that Xigris reduced the risk of death in sepsis patients to 25 percent, down from 31 percent with older treatments. But the details of the data from the trial left many scientists who reviewed it unconvinced of Xigris’s efficacy. Half of the 20 scientists who reviewed the drug for a Food and Drug Administration advisory committee hearing in October 2001 said the agency should not approve the drug without more data. A month later, the F.D.A. approved Xigris, but warned that its use should be limited to the sickest patients, where it appeared to have the greatest efficacy."
But then came the guidelines to boost use of Xigris.
The NEJM authors conclude: "The challenges involved in producing first-rate guidelines and performance standards are only exacerbated by the intrusion of marketing strategies masquerading as evidence-based medicine."
From across the pond, The Guardian of the UK reports on a huge pharma-funded advocacy campaign, but one which the Brits may be smart enough to sniff out and control. Excerpts:
"Cancer United, which is due to be launched with a fanfare in Brussels tomorrow, is being presented as a pioneering effort by a coalition of doctors, nurses and patients to push for equal access to cancer care across the EU. However, the campaign is being entirely funded by Roche, the maker of Herceptin and Avastin. A senior company executive sits on the board. The company's PR firm Weber Shandwick is the secretariat and has been heavily promoting it to clinicians and journalists. And the principal study on which it is based has been hotly contested - and was also funded by Roche.
MEPs and the head of the European Cancer Patients Coalition have already withdrawn from Cancer United's executive board, amid concerns over the funding and lack of transparency.
Roche last night strongly denied the campaign was in effect a marketing exercise.
However, one of the UK's leading cancer experts, Michel Coleman from the London School of Hygiene and Tropical Medicine, told the Guardian he had grave concerns about Cancer United.
"Governments will no doubt be pressed to fund a big increase in expenditure on cancer drugs - on the entirely spurious grounds that such an increase has been proven to increase national survival rates. I wonder if all the dignitaries on the executive board of Cancer United are aware of this murky background.
"Cancer patient groups should think twice before accepting sponsorship from Cancer United."
He is highly critical of the study that is central to the campaign. The report, from the Karolinska Institute in Stockholm, links patient survival to the amount their government spends on drugs.
Prof Coleman said the report represents "woefully simplistic research... This is clearly nonsense. For most cancers, higher survival results from earlier diagnosis and a combination of expert surgery and/or radiotherapy, as well as from the use of cancer drugs. ... One can be highly critical of European inequalities in cancer survival - and I am critical - but attempting to manipulate public opinion or national cancer policies on the basis of poor science about the availability of cancer drugs is not the right strategy for addressing those inequalities," he said."
Harvard's Bob Blendon, in an analysis of public opinion surveys on the Health Affairs website, summarizes Americans' attitudes about health care reform going into the mid-term elections. Excerpt:
"Most U.S. news coverage about medical care issues during the past year has concentrated on Medicare’s new prescription drug benefit, while many in the research and professional community have focused on the nation’s quality-of-care problems. What is important to recognize is that these are not the American public’s top health care priorities today. Americans want their government to do something about their rising health care costs and the problems of the uninsured. When Americans talk about health care costs, however, their concern is not for the share of the nation’s gross domestic product (GDP) going toward health care, but rather the financial impact on their own families."
The anti-climactic news is out: UnitedHealth chairman and CEO Bill McGuire will be replaced because of questionable stock option practices. The Star Tribune reports that McGuire's current balance of unexercised options was valued at more than $1.6 billion at the end of last year. It also reports that "McGuire isn't the only one implicated in the options controversy. (Company president and COO Stephen) Hemsley (who will replace McGuire as CEO) held options valued at $663 million at the end of 2005. In addition, 10 outside members of the board have cashed in options worth more than $159 million in the past five years."
There are many followup questions. What were the ethics of the management team of this health care industry giant? How can so many become so wealthy from an industry that fails to reach more than 46 million Americans without insurance? Are these the practices that should be expected from a company that gains so much from the Medicare prescription drug plan and from the push for "consumer-driven health care" plans?
Another one of my web efforts, HealthNewsReview.org, was named Cool Site of the Day by The Kim Komando Show one week ago today. Komando says she “hosts the largest talk radio show about computers and the Internet.” The program is heard on over 450 stations throughout the United States. One thing is known: traffic to HealthNewsReview.org soared. This week, the site registered more than 1.3 million hits and had more than 30,000 unique visits. Almost 400 of those visitors became registered users.
After just six months of operation, we have reviewed 208 health news stories on the site.
The Wall Street Journal (subscription required) reports:
"At the national Brain Tumor Foundation, executive director Rob Tufel has a standard reply for well-meaning families and patients who want to set up a patient-advocacy group: 'Please don't start another organization.'
There are 141 patient-advocacy groups that cover brain tumors, according to Mr. Tufel, while 43,000 people in the U.S. are diagnosed every year with primary brain tumors, benign or malignant. That's roughly one group for every 305 new patients. 'It just doesn't make sense from the point of view of funding, or from the point of view of patients and families,' who must sort through the numerous organizations and Web sites for information, Mr. Tufel says. 'Competition is good because it keeps us on our toes, but at some point ... it becomes ineffective.' ...
Many of these groups wind up competing with each other for the same donors and the same researchers to sit on their boards. There is the chance that groups will duplicate one another's efforts, wasting resources by offering the same programming or services. And busy legislators find themselves uncertain about what the greatest need is for patients because each group emphasizes different issues or aspects of the disease."
The WSJ reports that many overlapping advocacy groups are now investigating whether it is possible to set a common agenda and speak with a unified voice.
One oversight in the story: there is no mention of the amount of industry support that many patient advocacy groups receive. Such industry support may lead to biased, imbalanced information being disseminated to group members, and advocacy on behalf of industry interests instead of just patient interests. It's an issue worthy of much closer scrutiny by those who think of joining, or contributing financially to, such groups.
For a good story on this topic, see this Washington Post piece.
A little item you may have missed from the AP last week:
"Pharmaceutical companies increased advertising spending by 9% in the first half of this year, suggesting they no longer feel constrained by complaints raised after the landmark withdrawal of the pain medicine Vioxx.
Spending rose to $2.46 billion in the six-month period as drug makers devoted larger portions of their budgets to magazine ads and poured more funds into campaigns to promote their images and disease awareness, according to TNS Media Intelligence. In the first six months of 2005, spending was essentially flat at $2.26 billion.
The Vioxx withdrawal in late 2004 cast a pall over pharmaceutical advertising as critics claimed drug makers' splashy campaigns minimized medicines' risks. Vioxx was a heavily advertised Merck & Co. pain reliever that was found to increase patients' risk of heart attacks and strokes.
Earlier this year, the pharmaceutical industry adopted voluntary guidelines to improve the accuracy and balance of ads so the severity of drugs' side effects aren't whitewashed. That is easier to accomplish in magazine ads so drug makers are using that medium more frequently, Jon Swallen, research director at TNS."
That last comment is a bit deceiving. Pharma may be using magazines more frequently, but they're still spending "only " a third of their money in that medium. TV - where the side effect whitewashing can still occur more easily - still gets the lion's share of the spending - 59%.
Last week the San Jose Mercury News reported, "The halls of Stanford University Hospital and Clinics will be just a little bit quieter today, the first day of a new ban on drug and device sales people bearing gifts, gratuities and unsolicited advice."
The story touches on this trend at Kaiser Medical Group, Yale, Penn and elsewhere.
One Kaiser exec says in the story, "The amount of waste created by the marketing activities of these companies is borne by patients.''
The Wall Street Journal today published (subscription required) the fourth in a series of articles on middlemen striking it rich in the health care marketplace.
This one is a gem. Excerpt: "For years, a little-known unit of publishing giant Hearst Corp. called First DataBank has played a powerful role in determining what Americans pay for prescription drugs. First DataBank doesn't buy or sell drugs -- it publishes lists of drug prices. Health plans and state Medicaid programs use those prices as a benchmark in determining what they pay pharmacies.
If the benchmark goes up, so do costs for these payers. That's what happened in 2002, when First DataBank suddenly made broad revisions to its key published list. The new prices had the effect of fattening the profits of pharmacies, out of the view of patients and companies who pay for the soaring cost of health care."
What we don't know about U.S. health care is killing us - or our personal bottom lines.
The editor of Milwaukee Magazine writes: "Perhaps the most under-covered issue in the Milwaukee metro area is the cost of healthcare. Medical costs are killing this community in both public and private sectors.
Last week, a study by the Greater Milwaukee Business Foundation on Health Inc. found that physician fees for 13 procedures done by specialists are 30% to 40% higher in the Milwaukee area than in several other Midwestern cities. The group previously found that hospital costs in the Milwaukee area were among the nation’s highest. And past studies by others have shown that Milwaukee’s overall medical care costs were 25% higher than in other metro areas. ...
How can you possibly freeze taxes and continue services when your operations, as is true of all governments, are heavily driven by personnel, by employees who get health insurance coverage? When one of your biggest costs has gone up 87%, more than four times faster than inflation, how do you avoid budget increases? Adding to the irony is that any property tax increase to help defray these costs will not be paid by hospitals because they are tax-exempt nonprofits, even though they annually report “profits” and pay their executives mega-salaries.
Meanwhile, consider the impact on the private sector. How can Milwaukee’s businesses compete with those elsewhere when they are forced to absorb a cost for health insurance premiums that is so out of control? The business lobbying group, Wisconsin Manufacturers & Commerce, jumps on every tax that impacts businesses. Meanwhile, it seems to ignore a tidal wave of annual added costs coming from medical care inflation.
Ironically, local business leaders sit on the boards of local hospitals that are helping to drive these costs ever upward. Traditionally, these volunteers help raise donations for hospitals. Today, their time might be better spent demanding an explanation of rising costs.
I don’t claim to have any solutions to this crisis. But it’s a safe bet nothing will happen until more attention is paid to the issue. And the media can help make that happen." (my emphasis added)
A new study by the Center for Studying Health System (HSC) change shows that "health spending growth continued to outpace overall economic growth in 2005." Excerpts of the HSC news release:
"Health care spending continues to grow at a much faster rate than workers' income, making health insurance less affordable to more and more people, especially low-to-moderate wage workers and their employers," said Paul B. Ginsburg, Ph.D., president of HSC, a nonpartisan policy research organization funded principally by the Robert Wood Johnson Foundation.
"We're already seeing evidence of the growing health insurance affordability problem as more Americans become uninsured," said Ginsburg, coauthor of the Health Affairs article—"Tracking Health Care Costs: Continued Stability But At High Rates In 2005".
For the fifth year in a row, employers in 2006 increased patient cost sharing, through higher deductibles, copayments and coinsurance, as a way to cope with high premium increases. Without this so-called benefit buy down, or change in benefit structures, the premium trend would have been higher in recent years.
"Over time, premium increases cannot be lower than underlying cost trends, without benefits shrinking," Ginsburg said. "So major relief from the financial burden of rapidly rising premiums does not appear to be on the horizon, and the premium trend is unlikely to continue to decline in the coming years."
The Center for Science in the Public Interest reports that "The Journal of the American College of Nutrition's June supplement on sodium intake and human health failed to reveal that its editor and several authors had long-standing ties to the food industry. Then, in violation of the National Library of Medicine's rules, the editors allowed MEDLINE to index the supplement."
A CSPI news release also states: "In a letter to JACN, CSPI demanded that the next issue contain a formal apology to readers, full conflict-of-interest disclosure information for all authors and a prominent notice that the supplement did not undergo peer review. In a separate letter to the National Library of Medicine, CSPI requested that the abstracts be withdrawn from MEDLINE since the journal failed to follow NLM policy. The agency recently ruled that privately-sponsored journal supplements must contain conflict-of-interest disclosures for all authors and editors before they can be indexed in the government-funded database."
Here's a followup to last week's ridiculous New York Times column arguing that the U.S. doesn't need to restrain health care spending. Read the Reuters story that reports what we've heard before: "The United States spends far more on health care than any other country but gets only mediocre care in return for its investment."