• Better fundraiser

    My wife saw this on Facebook:

    better fundraisers

    I could not love this more.

    @afrakt

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  • AcademyHealth: Medicare payment cuts, hospital closures, and patient harm

    When Medicare cuts payments to hospitals, what happens? It may not be all bad. My new AcademyHealth post explains.

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  • AJMC: Patient engagement

    Last fall, I participated in a series of discussions hosted by the American Journal of Managed Care about health reform and the changing health insurance and delivery landscape. The video below is one exchange from the series, focused on patient engagement.

    I was joined by

    • Leah Binder, President and CEO of The Leapfrog Group
    • Margaret O’Kane, President of the National Committee for Quality Assurance
    • Matt Salo, Executive Director of the National Association of Medicaid Directors
    • Dennis Scanlon (moderator), Professor of Health Policy and Administration and Director of the Center for Healthcare and Policy Research, College of Health and Human Development, The Pennsylvania State University

    I’ll post other videos from the discussion series, but if you can’t wait, you’ll find more here.

    @afrakt

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  • Not today, death

    Via Jermaine Warren:

    death

    Margaret Farenger says this is on the side of Fulton County Health Services, Atlanta GA and the artist is Julian Hoke Harris.

    @afrakt

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  • The Gobeille decision is good for some organizations, but not the ones you may want to help

    Nicholas has been all over the Gobeille v. Liberty Mutual case and decision, but, at STAT, Yevgeniy Feyman and I spin out one implication a bit further:

    The Court’s blow to transparency doesn’t hurt everyone. Large, consolidated hospital systems, which usually provide higher-cost care, are the primary beneficiaries of price opacity. After all, if you’re the most expensive hospital in your market, why would you want that information made public?

    We also explain how the decision is good for dominant insurers.

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  • Fighting drug addiction with drugs works, but only if doctors sign on

    The following originally appeared on The Upshot (copyright 2016, The New York Times Company).

    Almost one million American physicians can write a prescription for an opioid painkiller like Vicodin and OxyContin — one pathway to opioid addiction. But, because of regulatory hurdles and other factors, fewer than 32,000 doctors are permitted to prescribe buprenorphine, a medication to treat such addiction.

    That’s a statistic worth thinking about since opioid painkillers and heroin contributed to the deaths of nearly 30,000 Americans in 2014, triple the number in 2000. Perhaps many of these lives could have been saved with buprenorphine. The Obama administration intends to increase access to it — and its proposed budget would commit hundreds of millions of dollars to do so — but it won’t be easy.

    Taking buprenorphine or methadone, alongside counseling, is the most effective approach to opioid addiction treatment. Because the drugs relieve patients’ cravings for heroin or narcotic painkillers, patients taking them can focus more on recovery and less on getting high. When taken properly, the drugs can help addicted patients and their families get their lives back to normal while reducing the risk of fatal overdose, crime and their societal costs. But the need for these treatments far outstrips available supply. Less than half of the 2.5 million Americans who could benefit from medication-assisted treatment for opioid addiction receive it.

    Expanding the use of methadone will be difficult. Methadone is provided dedicated clinics. But many communities resist clinics because they attract patients with addictions, a highly stigmatized population. Work by Christopher Jones, a pharmacist and public health researcher, showed that the number of patients treated at them has barely increased in over a decade. Most methadone clinics operate at or near capacity, and some have waiting lists.

    Expanding buprenorphine use could be simpler, but is still fraught with challenges. Though used to treat opioid addiction, buprenorphine, like methadone, is an opioid-based medication, so it too can be abused if improperly used. However, it does have a lower overdose risk than methadone. Since 2000, buprenorphine can be prescribed by qualified doctors to a limited number of patients to take at home. Buprenorphine use has expanded as a result, but availability is limited by regulation. Doctors may prescribe it only after taking an eight-hour course and applying for a special license. No such hurdles are required for prescribing any opioid painkillers.

    Buprenorphine use got a boost in 2006 when another change in the law permitted physicians who have held the special license for at least a year to prescribe buprenorphine to as many as 100 patients at a time, up from 30. Because the drug can be misused or diverted for illicit sale, the limit is in place to prevent the emergence of buprenorphine “pill mills” — clinics that make a buck from high rates of prescription and with insufficient patient oversight.

    A study led by Dr. Bradley Stein of the RAND Corporation found that this change increased access to treatment. But the regulated supply has not kept pace with the need. Dr. Jones’s study found that even if all doctors who are approved to prescribe buprenorphine did so to the maximum number of patients permitted by law, one million patients who could benefit from it would still be unable to obtain it.

    Last fall, Sylvia Burwell, the Health and Human Services Secretary, announced plans to remove regulatory obstacles to buprenorphine. The agency wants to increase the number of doctors who prescribe the drug and will also consider expanding the types of clinicians who are permitted to do so. H.H.S. is also planning to revise the rules governing the number of patients to whom doctors can prescribe the drug, though precisely how has not been announced.

    Now, the bad news. Many doctors are reluctant to prescribe buprenorphine; only 2.2 percent have met the regulatory requirements. Most of those limit the number of patients they treat below the maximum allowed by law, so increasing that maximum alone would probably have little to no impact.

    Of 78 primary care physicians surveyed for one study published in 2014, 64 percent had obtained approval to prescribe buprenorphine, but only 28 percent did so. And half of those treated only three patients, well below the lawful maximum. Chief barriers to increased prescribing cited by these physicians were lack of confidence in managing addiction and insufficientmental health support in doing so.

    “Increasing availability of medication-assisted treatment will require far more than just allowing doctors to prescribe buprenorphine to more patients,” Dr. Stein told me. “Fostering greater ability and willingness among doctors to effectively manage the growing numbers of addicted patients is an uphill battle.”

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  • AJMC: Choosing Wisely

    Last fall, I participated in a series of discussions hosted by the American Journal of Managed Care about health reform and the changing health insurance and delivery landscape. The video below is one exchange from the series, focused on inefficient utilization and Choosing Wisely.

    I was joined by

    • Leah Binder, President and CEO of The Leapfrog Group
    • Margaret O’Kane, President of the National Committee for Quality Assurance
    • Matt Salo, Executive Director of the National Association of Medicaid Directors
    • Dennis Scanlon (moderator), Professor of Health Policy and Administration and Director of the Center for Healthcare and Policy Research, College of Health and Human Development, The Pennsylvania State University

    I’ll post other videos from the discussion series, but if you can’t wait, you’ll find more here.

    @afrakt

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  • Actual textbook physics problem

    Via Xeni Jardin:

    physics prob

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  • How to make the most of drugs we already have

    The following originally appeared on The Upshot (copyright 2016, The New York Times Company).

    Though you may not have realized it, there’s a good chance that a doctor has prescribed you a medication for a use other than what it was approved for. This off-label use is perfectly legal, but isn’t as safe as it might be, in part because incentives to invest in costly clinical trials to test such uses are weak.

    One out of five prescriptions is off-label. Some drugs, like those for cardiac conditions and anticonvulsants, are used off-label at a much higher rate.One study found that an average drug is used for 18 different conditions.

    But the vast majority of off-label use lacks strong evidence of safety and effectiveness. The monetary incentives to invest in costly clinical trials to demonstrate them are weak. So it’s not a surprise that off-label use is associated with a 44 percent greater risk of having an adverse event or side effect than with on-label use, according to a recent study. Side effects can be as mild as dry mouth or as severe as heart rhythm abnormalities.

    “Clinicians frequently prescribe drugs off-label without knowing how well they work,” said Dr. Walid Gellad, a doctor at the University of Pittsburgh. “Sometimes it’s clinicians’ fault for not knowing the research. But sometimes the research just isn’t there.”

    The incentive to discover a useful new drug is clear. Patents and exclusive marketing rights granted by the Food and Drug Administration enable drug companies to profit from a monopoly. The monopoly prices allow them to earn enough to recover the cost of developing new drugs — the ones that succeed and the attempts that fail — as well as profit. There is no comparable incentive to investigate the use of existing drugs as solutions for other health issues, what the University of Michigan law professor Rebecca Eisenberg termed “the problem of new uses.”

    Despite the limited financial incentives and investment, over time, some valuable new uses of previously developed drugs have been found. Sometimes new uses are discovered by accident or through publicly sponsored studies. The diabetes drug metformin appears useful in treating breast cancer. Thalidomide, the morning sickness treatment that causedbirth defects, is now approved for the treatment of multiple myeloma, a type of blood cancer. In 2012, researchers experimenting on mice discovered that a cancer treatment drug showed encouraging early signs of effectiveness against Alzheimer’s disease.

    But there is little incentive to evaluate an existing drug for additional uses to the extent required for F.D.A. approval. Though obtaining that approval would be cheaper than developing a new drug, drug companies can encourage off-label prescribing with even cheaper studies than the F.D.A. requires. Additionally, more rigorous testing of drugs for new uses might illuminate harms, hampering drugs’ marketability rather than helping it. With little to gain and a lot to lose, companies aren’t eager to invest in new-use studies.

    “Why bother spending millions to get F.D.A. approval of a new use for a medication, when one small study, some key opinion leaders and an army of sales representatives can do the trick instead?” Dr. Gellad said.

    Once a drug’s market exclusivity period expires and generics enter the market, companies have even less incentive to test their products for new uses. Generic competition pushes down prices of drugs, which is good for patients who could not otherwise afford them. But at those lower prices, companies cannot recoup the costs of clinical trials to test drugs for new indications. What’s in it for them?

    But, by not exploiting existing drugs to their fullest, we may be denying ourselves many useful treatments, even for conditions for which there are none.

    One approach to encourage safer off-label discoveries is to spend more on government-sponsored studies. This might be done with direct grants for new-use research — already a focus of the National Institutes of Health — or through the sponsorship of prizes for the discovery of or execution of clinical trials for new uses.

    There may also be a more market-based approach. The government could (and already does) grant patents and periods of market exclusivity for new uses of generic drugs. But, without other changes, this is of little value. Today, pharmacists typically can’t tell for what affliction a prescription is being filled. It’s therefore of little consequence that one generic version of a drug has market exclusivity for a particular medical problem if a different one would work just as well. The pharmacist has no reason not to substitute one for the other, and is often legally or contractually bound to do so.

    Moreover, if a drug company cannot ascertain the problem for which a prescription is written, it lacks the means by which it can enforce its new patent. Therefore, it cannot recoup, through higher prices, expenses for investing in new-use research.

    This is a solvable problem, says Benjamin Roin, assistant professor of technological innovation, entrepreneurship and strategic management at M.I.T. He suggested a universal electronic prescribing system that tracks prescriptions and conditions for which they’re intended. This is feasibleand exists in Quebec. With such a system in place, a new-use innovator could charge more for the patented new use, and it would be easier to tell when a competitor is breaking the law by selling its product for that use.

    The problem of free-riding by competitors on others’ investments is common in health care. The sector is rife with relatively lower-cost ways toimprove health but with insufficient means of monetizing them, so they are understudied and underused. Solving the free-rider problem — including for new uses of existing drugs — could promote greater value for our health care dollar.

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  • AJMC: Implementing payment changes

    This past fall, I participated in a series of discussions hosted by the American Journal of Managed Care about health reform and the changing health insurance and delivery landscape. The video below is one exchange from the series, focused on implementing payment changes. My few comments were on CalPERS’ reference pricing.

    I was joined by

    • Leah Binder, President and CEO of The Leapfrog Group
    • Margaret O’Kane, President of the National Committee for Quality Assurance
    • Matt Salo, Executive Director of the National Association of Medicaid Directors
    • Dennis Scanlon (moderator), Professor of Health Policy and Administration and Director of the Center for Healthcare and Policy Research, College of Health and Human Development, The Pennsylvania State University

    I’ll post other videos from the discussion series, but if you can’t wait, you’ll find more here.

    @afrakt

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