Unnecessary care – Defo Says

Access, Behavioral health, carfentanil, fentanyl, Former US Representative Patrick Kennedy, Healthcare economics, Healthcare waste, Heroin, Opioid, Physician, Population health, Public health, Quality, Safe Injection Facility, SIF, Substance Use Disorder, SUD, Uncategorized, Unnecessary care

Prescription for the US opioid crisis: An interview with former congressman Patrick Kennedy (Part 2 of a two part series)

April 2, 2018 No Comments

In this hard hitting, no holes barred interview, former Rhode Island congressman Patrick Kennedy discusses what it will take to successfully combat and reverse our generation’s biggest public health crisis, the opioid epidemic. Does the US have the will for success?

Steve Defossez: What do you think it will it take for this country to develop the political will necessary to actually stem the tide of the opioid crisis?

Patrick Kennedy: Not to sound like a downer but …we couldn’t wrap our arms around the invisible wounds of war for our citizen soldiers the way we need to do to address suicide; (acknowledging the obvious tragedy of 23 soldiers dying a day, in many cases for totally preventable suicides). If we couldn’t get a significant tranche of money for the opioid crisis given the epidemic that’s ongoing, it’s really hard for me to know what it is going to take to spur that kind of political will.

Steve Defossez: Once an effective treatment for HIV-AIDS was discovered, the death rate from HIV-AIDS started coming down right away. Yet similarly effective medication assisted therapies were developed for opioid use disorder years ago, and they have not been widely deployed; hence the death rate from opioid overdose continued to increase.

Patrick Kennedy: The comparisons are that during the HIV-AIDS epidemic, we were spending $24 billion a year to save these patients. And that made a big dent changing the whole fatal nature of HIV-AIDS. Today, we’re spending less than half $1 billion, on the opioid epidemic when we were spending $24 billion on the HIV-AIDS epidemic.

(It should be noted after this interview, Congress passed and the president signed the recent bipartisan spending bill which does include 4 billion dollars to combat the opioid epidemic. This is not allocated solely to fund treatment, however. It also funds opioid prevention, research and law enforcement.)

Steve Defossez: We need to open up people’s eyes to the fact that the genetic predisposition to addiction, like karma, is written indelibly into our genes at the moment of conception. Opioid addiction is as much of a “physical disease” as appendicitis is.

Many patients really want to feel normal again, to get out of the cycle of withdrawal symptoms and use, but they don’t see an alternative to avoid withdrawal besides the use of heroin.

I was told by a hospital CEO in the US Southwest that, when a patient without medical insurance presents to their emergency department with an opioid overdose, they are resuscitated and then immediately discharged back into the community, with no hope of accessing medication assisted therapy, because medication is simply unavailable to patients without insurance in her county. It’s stunning that in a country as rich as ours, which spends 20% of its GDP on healthcare, there is no treatment for these patients.

“And the persistence of this problem is so inexcusable.”

Patrick Kennedy: What’s also stunning is that the hospital CEO wouldn’t follow-up that statement by saying, “and I have therefore made a directive that as hospital CEO, my staff and my doctors will provide that medication assisted treatment, and we are going to work with our local community college to get the necessary peer support specialists etc. We will do that right here on the campus of our hospital.” That’s the appropriate follow-up line. Everyone thinks it needs to be someone else’s job, you know, send them somewhere else. And if they are rich, they can fly to some other part of the country. When in reality, they need to go to their hospital right down the street, where they go for everything else; they need to go there for this care too.

Steve Defossez: And today there isn’t parity. If that patient was pregnant and in labor, they wouldn’t say “oh, you don’t have insurance, leave the hospital.” But for patients suffering from opioid substance use disorder, they do say that.

“Bottom line; hospitals and doctors need to offer medication assisted therapy, as part of their moral responsibility…”

Patrick Kennedy: And the persistence of this problem is so inexcusable. Because as I said the template is pretty simple. They’re going to have an injectable medication. There are several companies coming up with different forms of injectable buprenorphine (medication). All of the insurance companies said they’re going to be reimbursing for this. CMS (Centers for Medicare & Medicaid Services) could easily do a bump up in opioid use disorder reimbursement payment. I’ve talked to them about doing this and they may well be on the track to doing that.

Patrick Kennedy: Bottom line; hospitals and doctors need to offer medication assisted therapy, as part of their moral responsibility, as the chief healthcare provider in the community. It’s hospitals that need to do this, it’s doctors that need to do this.

Patrick Kennedy: The AMA needs to step up. We know it takes eight hours of training to become certified to utilize these medications to treat substance use disorder. Physician organizations should just say you know what? We are going to incentivize that training. We’re going to make payment increases for substance use disorder a top priority. In addition, we are working with the National Council Of Behavioral Health to provide wraparound services. So doctors, you don’t need to do anything but write a prescription for the buprenorphine. Let the community mental health activists and those in the community recovery movement take it from there.

“It’s disappointing that there is so much lack of imagination in the space.”

Patrick Kennedy: This can be put together. I’ve run campaigns, not only for my own case, but for many others, for a long time. We know what the essential elements are for a good campaign. We know how to do it. The playbook is roughly the same. You make some small changes depending on where you are. This is not complicated stuff. It’s not a heavy lift to do. And I guarantee you that a lot of insurance companies would like to do this, because they don’t like the increased costs foisted on the system by undertreatment of opioid addiction.

Patrick Kennedy: With alternative payment models, such as Accountable Care Organizations (ACOs), hospitals and providers are increasingly taking on insurance risk, and are responsible for the total cost of care. They do better financially when they deliver high quality care, utilizing the fewest resources. In an ACO model, hospitals could negotiate increased reimbursement rates for providing mental health treatment and treatment for opioid addiction with these insurers. The rationale would be that we are going to treat the whole person, and be rewarded with lower overall healthcare costs and healthier patients. There are experts who can show that if we treat opioid addiction appropriately, we can easily expect to achieve over a four times lower cost of “physical healthcare” costs. This is the real result of putting somebody into a chronic care management program for addiction.

Patrick Kennedy: There is no rational way to explain why this isn’t already being done. It’s not because we don’t know what to do. It’s not as if we don’t have the reimbursement mechanisms that can be devised to make this a value proposition, especially in this new era of value-based payments. It’s disappointing that there is so much lack of imagination in the space.

“It would be my bet that perhaps one of the single biggest returns on investment in healthcare that we could expect today is to improve the quality of our mental health delivery system, as part of our healthcare system.”

Steve Defossez: Do you think integrated care is the future of mental health and addiction service delivery? What needs to happen to increase its uptake?

Patrick Kennedy: We need to align the financial incentives for optimal outcomes across the entire mental health – physical health spectrum. The optimal outcome is the reduction in the reoccurrence of illness, complications to illnesses and unwanted conditions such as readmissions to the hospital. If mental health issues factors into that, then pay for mental health treatment, at least to the degree that mental health factors into reducing those bad outcomes. It would be my bet that the current lack of mental health treatment factors into contributing to bad health outcomes in a big way.

Patrick Kennedy: In fact, it would be my bet that perhaps one of the single biggest returns on investment in healthcare that we could expect today is to improve the quality of our mental health delivery system, as part of our healthcare system. This is because of how much it’s going to do for the rest of healthcare. I think that unfortunately, the value proposition to cancer will be depression treatment. The value to diabetes could be alcohol treatment. The value to all kinds of intellectual and developmental disabilities will be prenatal care. There are five times as many babies born today with alcohol and drug related complications than there are kids born with autism. The bottom line is, it is integration, integration, integration. Mental health in each and every one of those areas of medicine can be the decisive factor in changing the health of our population.

Steve Defossez: That’s right. 5% of the US public consumes 50% of our healthcare. When you talk to people who work in emergency rooms, there are patients who come into the emergency room several times a week, because of anxiety issues or homelessness and because they don’t have access to more appropriate and less expensive care.

Steve Defossez: A friend of mine is a healthcare CFO in California who noticed one of their patients (who was not particularly ill) was spending $200,000 a year on unnecessary emergency room visits. The patient was checking into the emergency room every two or three days with one complaint or another. When the CFO evaluated the root cause of this behavior, he discovered it was because the patient was homeless. So this CFO somehow arranged to get this patient a stable apartment. The following year, what you think the insurance company spent on his healthcare? The answer is the patient stopped visiting the emergency room altogether. The insurance company didn’t spend one penny on this individual’s health care the following year.

Steve Defossez: I’m not a constitutional scholar but we all know cruel and unusual punishment is banned by the US Constitution. I’m pretty sure if we addicted prisoners of war to opioids and then forced them to go through withdrawal, this would be considered torture. Yet that’s just what we do in the criminal justice system. If someone goes into jail with diabetes, no one thinks twice about giving them insulin. But I understand almost nobody gets medication assisted therapy for opioid use disorder while incarcerated. Hence they’re forced to go through withdrawal and suffer cravings. Particularly with the long acting injectable medications you discussed, proponents of this unconstitutional policy can’t use the argument that these medications might be used illicitly within the prison. Am I wrong that failure to provide medication assisted therapy is a violation of the US Constitution, and a violation of the Parity Act which you spearheaded in Congress?

Patrick Kennedy: That’s right, and then you have the very real incarceration of people with these illnesses and also people with full-blown psychosis, banging their heads against the jailhouse doors. I’ve seen that going into these prisons. We are in a bad place in this country regarding the treatment of people with mental illness including those with addiction.

Steve Defossez: The United States is an outlier in that we incarcerate more people on a percentage basis than any other nation. Part of this is that we incarcerate more people with mental illness than we hospitalize.

Patrick Kennedy: That sounds about right. That’s what we ended up doing, shifting them from the “asylums” to the new asylums which are obviously our jails and prisons.

Steve Defossez: Where you think the future of opioid substance use disorder is headed, including the concept of supervised injection facilities (SIFs)?

Patrick Kennedy: We have long acting buprenorphine in phase 2 trials. Indivior just gained FDA approval for a monthly injection of buprenorphine this past November

Some of the existing long-acting medications come with a catch in that they were administered through a large-bore painful needle. But now they are developing these new long acting injectable medications which can be injected through a tiny needle, like your flu shot. You’d only have to adjust a little bit of titration down from the use of heroin, prior to starting treatment with these medications. These injectables satisfy cravings and protect a person from overdose.

Steve Defossez: Yes, I understand these new long acting buprenorphine medications do not require patients to go through withdrawal or detox before use.

Patrick Kennedy: So it seems to me our first urgency ought to be to get these types of products out, because to your earlier point, people are looking for a way to stop that cycle of in – out, in – out. Substance use followed by detox, followed by substance use then detox. If you can stop the cravings and use, you can prevent them from overdosing. Why isn’t this treatment more widespread? Because it’s out there, it’s not fantasy.

Patrick Kennedy: I understand the harm reduction of supervised injection facilities SIFs, but it’s kind of like what you do when you have no other options. My point is we have these other options, let’s double down on our options, and put these injectables in every doctors’ office in the country, like we do with our flu shots. I know they’ve had success with SIFs in Canada. I’m on my way to Philadelphia now, so I should learn more about SIFs soon.

Steve Defossez: The safe injection facility concept is that people bring in the stuff from the street because they don’t want to stop today but they do want to not die. So they bring it in from the street and this does allow the employees to take microscopic samples of the heroin to see what’s out on the street, whether it’s fentanyl, elephant fentanyl etc. If the person overdoses in the building, they can be resuscitated so they won’t die. And of course because it’s a medical facility, there are staff there who can teach the patient how to inject in a sterile fashion so they don’t get bacterial heart infections, HIV-AIDS, hepatitis etc. While there, patients also have access to first-aid for superficial infections, a warm shower and food. Every encounter is a touch point where someone explains to the patients that when they are ready to choose recovery, we can offer that too.

Patrick Kennedy: I like that. I was very much for safe needles exchange 20 years ago in Providence when I was first a state representative there. And God, it was so hard to get it passed and now, you know, it’s obvious these days.

Conclusion: Every American should awaken to this simple fact: if this scourge has not yet found you or your family, without bold action by everyone, it soon will. I ask you to support cost-effective and life-saving medication assisted therapy by emailing your elected state and federal senators and representative and express your support for adequate funding for and widespread dissemination of this life saving therapy.

Affordability, Drug price, Healthcare economics, Healthcare waste, Pharmaceutical, Pharmaceutical prices, Physician, Population health, Public health, Quality, Uncategorized, Unnecessary care

A Dozen Cures For Overpriced Pharmaceuticals

February 14, 2018 No Comments

(Part three in a three part series)

1. Don’t fall victim to pharmaceutical value-based price anchoring: After Touring pharmaceuticals increased the price for Daraprim from $13.50 to $750 per pill, Stephen Lederer, a spokesman for Turing demurred, the pricing for Daraprim “reflected its clinical value.”

Imagine if surgeons priced their surgery this way: A surgeon is called to the bed of a 13 year old boy with a burst appendix and says, “Son, you have to ask yourself what is the ‘actual value’ of being alive for another 70 years? 6 million dollars you say? Well, then you should be happy to pay 5 million dollars for me to remove your appendix.” If the patient objected, the surgeon might add, “OK, I’ll enter into a value based contract with your insurer, and only collect the money if the surgery works.”

Don’t let the drug companies fool us into anchoring the price negotiation at the value of life, rather than the production cost of the drug.

2. Radical transparency: Sunshine is the ultimate antiseptic. Drug makers should publicly divulge the true cost of research and development for each drug, as well as what they charge for it. This is particularly true as healthcare is increasingly viewed by society as a right, not an option.

Vermont recently passed a law to this effect. Vermont requires drug makers to provide cost data on the 15 most costly drugs the state purchases.

One cannot identify, let alone fix, market breakdown until one views price in conjunction with cost. With fundamental production cost transparency, a miracle cure may still justify a higher price, but only if its development costs support that pricing.

3. Regulate big pharma like a public utility: Currently, their intellectual property rights allow brand name pharmaceutical companies unlimited pricing power for new drugs. This is the definition of a monopoly. Markets are not free if there is only one vendor. In America, if a product is considered essential, (such as electricity) we intervene in the market. Utilities open their books to utility regulators, and based on the cost of production, prices are set.

With pharmaceutical market breakdown, drug prices bear no relationship to the cost of production. A multidisciplinary regulatory commission can price a drug taking into account cost, overhead and reasonable profit, while protecting the public from price gouging.

4. Support the fledgling generic startup, Fair Pharma: Today, ruthless generic companies can corner the market by purchasing the sole generic manufacturer of a critical life saving drug, and overnight raise its price, 3000%. According to a recent report, when Valeant Pharmaceuticals purchased the rights to Cuprimine, used to treat a rare genetic disorder, Valeant next increased Cuprimine’s price from from $8.88 to $262 per pill.

Fair Pharma is a new nonprofit generic manufacturer spearheaded by Intermountain Healthcare. Fair Pharma is essentially a consortium of hospitals and health systems who have decided to band together to produce their own reliable supply of low cost generics. Their mission is not to maximize quarterly profits, but to maximize the free supply of low cost, high quality generic drugs to their patients and their customers’ patients.

5. Support drug reimportation or show me the dead Canadians: Patients in Canada and other countries pay 30% to 50% less than US patients because their governments successfully negotiate with the drug companies for significant discounts.

We could capitalize on these lower prices by allowing US drug stores and patients to re-import these less expensive drugs back into the US. This option is currently illegal. The supposed rationale for banning reimportation is that reimported drugs are somehow counterfeit, of low quality or unsafe. To which we paraphrase former Minnesota Gov. Tim Pawlenty, “show me the dead Canadians.”

Canadians are not dying from low quality pharmaceuticals. The reimportation ban is in actuality political payback to pharmaceutical firms. It is against the public interest. These medications are safe and purchased from the same manufacturers we buy them from.

Re-importation of drugs from Canada has support from activists on both sides of the political spectrum. Senator Bernie Sanders and President Donald Trump have both called for legalization of drug reimportation recently. 72% of Americans support allowing the reimportation of prescription drugs from Canada. Contrary to some paid alarmists, this can be accomplished safely. Most of these drugs are actually manufactured within the US already.

6. Allow the US government to negotiate drug prices: Canada and European countries successfully negotiate with the drug companies for significant discounts. The US government should likewise negotiate the price of the drugs it purchases. The US government is the largest purchaser of these drugs in North America. Yet US taxpayers pay more than any other consumer in the world for these medications. In any rational market, we would be entitled to a discounted price. This is a grotesque example of the US Congress capitulating to a special interest as opposed to representing the public interest. Congress actually passed a law making it illegal for the government to negotiate the price of the drugs it purchases.

This common sense solution enjoys overwhelming support from the US public; 92%. It also enjoys bipartisan support: Senator Bernie Sanders and President Donald Trump both support this obvious cost savings. Change the law. Enough said.

7. Use generics when appropriate: Hospitals, physician groups and health plans should encourage doctors and other prescribers to use lower cost generics whenever there is a lower cost generic of equivalent effectiveness.

8. Encourage so called “step therapy”: Step Therapy is an approach where inexpensive yet effective medications are tried first, prior to the prescription of more expensive medications.

9. On long term stable medications? Buy them in bulk. Encourage patients who are on chronic, long term, stable medications to buy them in bulk from the most cost effective source, often mail order.

10: Support prescribers with Clinical Decision Support: Encourage Electronic Health Record developers to include effective pharmacy Clinical Decision Support in order to insure prescribers have updated information regarding drug cost and efficacy at the point of order entry (when they are actually prescribing the medication).

11. Payer transparency: Insurers should provide patients and physicians alike with an up to date, fully transparent formulary of covered medications, alternatives, including information on patient co-pays, differing price tiers and generics.

12. Eliminate TV advertising by the drug companies to the consumer: The American Medical Association supports this solution, as they fear this advertising unnecessarily drives up demand for expensive drugs.

This would remove a large cost from the pharmaceutical industry. The only other developed country in the world which allows drug company executives to advertise directly to the public is New Zealand. (New Zealand physicians are also lobbying for a ban there too.) Banning ads will result in reduced drug prices, reduced inappropriate demand for drugs by patients and therefore, reduced medical harm from unnecessary side effects.

Perversely, given the complex US tax code, US taxpayers are actually subsidizing the very ads which drug companies utilize to drive up demand and prices for their products. Drug company TV ads are currently considered a legitimate tax deductible business expense.

I ask you to support these cost-effective and life-saving proposals by emailing your elected federal senators and representative to express your support for for this path to the future.

Affordability, Behavioral health, fee-for-service, Healthcare economics, Healthcare waste, Population health, Public health, Uncategorized, Unnecessary care

Wasteful healthcare spending hurts us all: Report from the National Affordability Summit

October 2, 2017 1 Comment

Healthcare leaders, policy experts and pundits recently gathered in Washington DC at the National Affordability Summit hosted by NRHI.

Twin themes driven home effectively at the Affordability Summit were:
1. Overspending on US healthcare damages our society.
2. Lots of unnecessary, potentially harmful, and wasteful care is happening and it is fostered by the fee-for-service system.

Overspending on US healthcare can be defined as growth in US healthcare spending greater than the growth of the US Gross Domestic Product (GDP). The US spent approximately $3 trillion on healthcare expenditures last year. As government spending currently accounts for about 2/3 of all US healthcare spending, allowing healthcare spending growth to go unchecked could make the recent Greece debt crisis look like a bump in the road.

This rapidly growing healthcare spending is the driving force behind our federal deficits. Princeton economist Alan S. Blinder has written: “The implication for budgeteers is clear: If we can somehow solve the health care cost problem, we will also solve the long-run deficit problem. But if we can’t control health care costs, the long-run deficit problem is insoluble.”

Overspending on US healthcare damages society by:

Driving impending insolvency at every level of government (federal, state, county and municipal).
Crowding out spending on all other government priorities (social services, education, national defense, public safety, transportation, etc.).
Squeezing employer profits, reducing American competitiveness in world markets.
Raising the cost of US labor, thus discouraging US firms from hiring US workers and encouraging outsourcing jobs overseas.
Raising the cost of US made goods and services in comparison to overseas goods and services.
Capping wage growth. (Healthcare insurance premium growth has sucked up what employers otherwise could have devoted to increased wages for the middle class.)
Causing some citizens to skip necessary, or preventative medical care, resulting in patient harm and larger medical bills down the road.

As healthcare spending consumes an ever increasing portion of the federal budget, the very principle of our representative democracy is at risk. How can our elected officials make decisions regarding allocating resources if nearly all of those resources have already been committed by previous administrations? George Will recently noted: “Most alarming is American democracy becoming a gerontocracy. The Steuerle-Roeper Fiscal Democracy Index measures how much of the allocation of government revenues is determined by current democratic processes and how much by prior decisions establishing permanent programs running on autopilot. The portion of the federal budget automatically spent by choices made years ago is approaching 90 percent.”

Lots of unnecessary, potentially harmful, and wasteful care is happening, and it is fostered by the fee-for-service system.

The Institute of Medicine suggests that 30% of healthcare spending is avoidable. Unnecessary care is not just wasteful, it actually hurts people. More than one speaker noted that if you want affordable care, “here’s an idea… Stop wasting 30 to 40 cents of every dollar we spend.”

The drivers of medical waste (unnecessary, and potentially harmful care) in the fee-for-service world include:

A fragmented, uncoordinated delivery system.
Misaligned incentives between patients, physicians, payers and society (which create artificial demand for unnecessary care).
Lack of routine access to clinical decision support.
Imperfect knowledge, both on the part of physicians and patients.
Unconscious and conscious bias to provide unnecessary care.
Lack of price and quality transparency, to both physicians and patients.
Under-investment as a society in the social determinants of health.
Poor transitions of care from one setting of care to another.
Unnecessary administrative burden, usually driven by insurers and government.
Defensive medicine, in an effort to ward off medical malpractice lawsuits. (One study suggests the US wastes 200 billion dollars each year on wasteful and unnecessay medical testing alone.)
Aggressive, unnecessary, and often harmful end-of-life care.
A failed behavioral health system.
Self-enriching self-referral. (This only exists in the fee-for-service world.)
Direct to consumer marketing of pharmaceuticals.
Inappropriate utilization by patients due to our third party payment system.
Medical errors.
A medical arms race of unnecessary, underutilized, and overpriced shiny new toys; surgical robots, proton beam machines, cyclotrons and high end imaging machines often bought to, “keep up with the Jones.”
Pharmaceutical price escalation. (If the pharmaceutical industry wants to price their miracle drugs at $475,000.00 per patient, as if they were a monopoly, then they should be regulated like a monopoly utility, but that’s a post for another day.)

How can we get to affordability? By eliminating wasteful healthcare spending.

Dr. Glenn Steele, Geisinger’s former president notes, “Our core belief is that about 40% of what doctors and hospitals do is wasteful. If you can extract that percentage of crap, you can redistribute it into savings and profits but also into procedures that actually help patients.”

Under the fee-for-service system, we won’t pay for a patient to call their doctor to ask if something is a true emergency, yet insurers will pay for their ambulance ride to the ER and for an unnecessary ER visit. Our current incentives are misaligned and incent unnecessary care. Fee-for-service is the enemy of population health.

Path to the future:

We won’t solve this problem by tinkering around the edges. We need an all-in, bold, new approach to healthcare reimbursement which rewards improving the health of the population. Today’s well-intentioned but hopelessly misaligned population health strategies and alternative payment models are built on the chassis of specialist fee-for-service payments. It’s specialists who drive most of the healthcare spending within the US. No physician’s salary should be volume driven. In a future post, I will explore what I call Accountable Specialist Care; a healthcare payment reform which can be embraced by specialists and has the potential to dramatically reduce wasteful healthcare spending.

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