• Obesity

    Shared by Brad Flansbaum (via this):

    obese david

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  • Ban drug ads on TV? Some positive outcomes would be lost

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

    If you’ve watched any television, you’ve seen drug ads — a lot of them. Drug companies spend several billion dollars a year on direct-to-consumer advertising. Count them and there are 80 drug ads an hour.

    Do drug ads provide useful information, as the pharmaceutical industry maintains? Or do ads just promote wasteful use of expensive new drugs, justifying regulation to rein them in? Those questions have taken on new importance as spending on drug ads has grown. Gilead Sciences, for example, spent $100 million on an ad campaign for its hepatitis C drug, Harvoni — the one that costs as much as $1,100 a pill.

    Americans are about evenly split on the educational value of prescription drug ads. But the American Medical Association recently called for a ban, arguing that TV drug ads merely drive demand for expensive treatments. Senator Al Franken, making the same argument as the A.M.A., has introduced a bill to withdraw tax breaks companies are permitted to take for their ad spending.

    Research on the consequences of drug ads presents a more nuanced picture. Advertising increases drug sales; the studies are consistent on that. It does so for the promoted drug, as one would expect. But it also increases sales of other, nonadvertised drugs for the same condition. For instance, Prozac ads lead to increases in prescriptions not only of Prozac, but also of Zoloft. Bradley Shapiro, an economist at the University of Chicago, found that the increase in the overall antidepressant market is larger than the market share gains made by just the advertised drugs.

    Why would one drug benefit from another’s ads? For stigmatized conditions, like depression and other mental illnesses, drug ads may serve to normalize them, encouraging sufferers to seek treatment, even if it’s not with the specific advertised drug.

    Doctors appear to benefit from TV drug advertising. Only they, and certain types of nurses, can prescribe drugs, so for advertising to increase their use, visits to physicians must increase. And that’s what studies have found. One-third of adults said that drug advertising prompted a discussion with their physician. Collectively, every $28 spent by drug companies per year on ads resulted in one more visit to a doctor that led to a prescription. One more person making one more doctor visit doesn’t sound like much, but drug companies spend billions on advertising.

    Interestingly, the A.M.A.’s call for an advertising ban does not extend to promotion aimed at doctors. Yet the drug industry spends about seven times more on visits to doctors’ offices by drug company representatives, free samples and advertising in professional journals than on ads directed at consumers. Physicians may more readily prescribe drugs they’re familiar with through these types of promotion.

    Though doctors often may yield to patients’ requests for a specific drug, in many cases they apply their own judgment and prescribe a different one, or none at all. When it comes to depression, a randomized controlled trialshowed that drug requests led to more appropriate care, though not always with pharmaceuticals. The study sent professional actors to doctors’ offices, where they pretended to have depression. Among those who did not request drugs, only 56 percent received appropriate care — any combination of an antidepressant prescription, a referral to a mental health professional or a follow-up appointment. Just one-quarter of the people requesting a specific drug received it; about half received no drug at all. But among those who requested a specific drug, 90 percent received appropriate care, but not all of it involved drugs.

    Another way drug ads can help patients is by encouraging them to continue with medication they’ve already been prescribed. According to one study, for every 10 percent increase in viewership of drug ads, between 1 and 2.5 percent more people adhere to their prescribed drug regimen. Several studies of spending on ads for statin drugs found that it was associated with a greater proportion of high-cholesterol patients who successfully brought their cholesterol levels under control.

    A study of advertising of antidepressants found that it was associated with an increase in the number of people who received antidepressants for the appropriate duration of treatment.

    Whether drug ads influence prescribing varies by condition. Ads for conditions that are easily tested — like high cholesterol or allergies — are more likely to lead to appropriate prescribing because there is little uncertainty as to whether the patient has the indicated condition.

    One study showed that advertising leads to greater sales for drugs that insurance companies encourage via lower cost sharing. Another showed that advertising increases sales of lower-cost, nonadvertised drugs. Put it all together and the link between a drug ad and a patient obtaining that particular drug is weaker than many might think.

    There’s little consistent evidence that ads substantially promote higher drug prices. One study found that only about 6 percent of the entire increase in prescription drug spending growth between 1994 and 2005 could be attributed to advertising-driven price increases.

    It’s unlikely that all uses of prescription drugs that ads encourage are beneficial. One study found that greater advertising led to more adverse reactions to drugs. So some people propose a compromise position on drug ads: allow them only for drugs that have been in use for several years, during which time safety can be more thoroughly assessed. Another way to approach the problem might be to promote use of effective drugs byreducing their prices or patients’ out-of-pocket costs for them.

    The evidence suggests that the A.M.A. is only partly right. Not all prescribing that drug ads promote is valuable, yet they encourage some helpful and appropriate care.

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  • AJMC: The Affordable Care Act

    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 the Affordable Care Act and how it’s going.

    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.

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  • Better fundraiser

    My wife saw this on Facebook:

    better fundraisers

    I could not love this more.

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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.

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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.

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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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