Summary: Last week, Medicare made the decision to commit to paying $93,000 per patient to cover Provenge, a cancer drug that promises to give the average patient suffering from end-stage prostate cancer  an extra four months–though it doesn’t appear to affect the progress of the disease. 
 For Wall Street investors who had put their money on the Dendreon, the drug’s manufacturer, this represents an enormous win. Cancer researchers also may have reason to cheer:  Provenge could mark a small step forward, opening another door in the long quest to find a cure using a patient’s own immune cells. But it is not at all clear that the government should be paying for the treatment outside of controlled trials. For today’s patients, the danger is that Medicare coverage will give them false hope. After all if the government is willing to pay $93,000, thieir must be a chance that Provenge will save lives, right? Wrong. 

The drug offers absolutely no promise of cure; at best it may extend life for a few months–or lengthen the process of dying, depending on your point of view.  Meanwhile tax-payers and other Medicare recipients are the losers. If Medicare is paying for yet another $100,000 cancer drug that offers only a marginal benefit, it will have that much less to spend on other, more effective, if less exciting treatments.  Finally the decision sets yet another expensive precedent, raising the odds that in the not-so-distant future everyone will have to pay higher Medicare taxes.  At some point, Medicare must just say “No” to drug manufacturers–and begin negotiating for lower prices. 
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Long-time readers may remember Provenge, the cancer drug I wrote about in 2007.  In March of that year an   FDA advisory panel voted 13 to 4 to recommend approval of Provenge. The next day, shares of Dendreon, the drug’s sponsor, doubled. But shareholders did not celebrate for long. Two of the dissenting votes were cast by the panel’s two prostate cancer specialists: Sloan-Kettering’s Howard Scher and the University of Michigan’s Maha Hussain. And they did not just vote “no”—following the hearing, both wrote to the FDA arguing that Dendreon offered no solid evidence that Provenge slow the progression of the disease.

The FDA listened. And it told the company it wouldn’t approve the drug until it had more data. That is when the two oncologists began receiving threatening e-mails, phone calls, and letters. Many were anonymous.

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Below, excerpts from a piece by Joanne Kenen that originally appeared in Health Affairs. 

Kenen is a health care journalist and author who spent more than a decade covering health policy on Capitol Hill. Here, she delves into the stopgap insurance plans that the federal government designed to cover patients suffering from pre-existing conditions while they wait for the final phase of the Affordable Care Act to roll out in 2014.  (Following Kenen’s post, you’ll find my comment on what I see as the core of the problem.)                          
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Conservatives Snipe at Preexisting Condition Insurance Plans
By Joanne Kenen
 “The Affordable Care Act is barely a year old, and its earliest initiatives are already coming under intense scrutiny . . . . Near the top of the list is the so-called Preexisting Condition Insurance Plans, the stopgap program created under the law to cover millions of uninsured people with preexisting medical conditions.  So far, enrollment in the eight-month-old program has fallen far short of expectations: Just 12,000 people had signed up as of February 2011. Now health reform critics are citing the program’s failings as indicative of a disaster to come: 

“’If the feds can’t manage this little project,’ wrote Indiana Gov. Mitch Daniels in a typical swipe in the Wall Street Journal, ‘What should we expect if they attempt it on a scale hundreds of times larger and more complex?”

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For first time ever,  the Office of the Inspector General (OIG) for the U.S. Dept. of Health and Human Services (HHS) is publishing a list, complete with the mug shots below, of HealthCare’s “10 Most Wanted Fugitives,”   individuals who have allegedly defrauded taxpayers of more than $126.6 million.   These are just 10 of the more than 170 fugitives on OIG’s list, and it is asking the public to help:  “For OIG, tracking more than 170 health care fugitives is a challenge. If you have a tip about a featured most-wanted fugitive, send the information our way.”

If you go to the webpage of mug shots  and click on the photos, you’ll find a brief bio and details  of the fugitive’s crime.

For instance, consider Tarek Wehbe: Between January 2002 and January 2007, Wehbe, a physician, allegedly submitted fraudulent claims to Medicare, Medicaid, and private health insurance carriers in order to obtain reimbursement for services that were either not provided, medically unnecessary, and/or over-charged.

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Fifty-seven year old Elissa Montati has little money and no training in humanitarian aid. All she has is “a computer and a phone” CBS correspondent Scott Pelley explained on 60 Minutes last night. Nevertheless, over the past 15 years, Montati, who lives alone on Staten Island, has transformed the lives of more than 100 children maimed, burned, and crippled in wars on five continents. She has done this by putting together a network of U.S. doctors and hospitals, one by one that agree to waive their fees and treat these children at no charge.

Montati runs her operation out of her former walk-in closet. “I added a window,” she explains. “And it works. I speak to the world right outta my walk-in closet.”

Asked where the 112 children she has helped come from, Montanti told Pelley, "Bosnia, El Salvador, Liberia, Niger, Sierra Leone, Iraq, China, Indonesia, Pakistan, Haiti. Did I say Nepal?"

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Below, a guest-post by David Spero, R.N.  Spero is the author of Diabetes: Sugar-Coated Crisis  — Who Gets It, Who Profits and How to Stop It, a book that Thomas Bodenheimer MD, Professor of Family and Community Medicine, University of California, San Francisco describes as “a hard-hitting and beautifully written look at the social causes and cures of chronic illness… illuminates the true reality of diabetes and provides cutting-edge ideas on prevention and treatment.” (Bodenheimer’s recommendation puts it on my “to-read” list.)

In this post, Spero explains why “free market competition” doesn’t work to bring us affordable health care. Quite simply, the seller has too much power. Drug-makers and device-makers set their own prices, with little push-back from public-sector or private sector payers. Lobbyists have managed to push through a law stipulating that Medicare cannot negotiate for lower drug prices. As for private insurers, they have found that if they don’t cover all of the drugs advertised on TV, they lose customers. So for the past ten years they have been shelling out whatever the manufacturer demands, while passing the cost on in the form of higher premiums.

In the case of doctors and hospitals the situation is more complicated.  As I explain in a note following Spero’s post, total reimbursements to providers have been spiraling–though some physicians and medical centers have enjoyed the lion’s share of the gains, while others have watched their income drop.

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A hospital’s Chief Medical Information Office (CMIO) should be a physician, says Pam Brier, president and CEO of Maimonides Medical Center “because nobody knows a doctor’s business like a doctor.” 
As a hospital’s information technology (IT) point person, a CMIO needs to be able to persuade physicians and other health care professionals that health information technology (HIT) can help them care for patients.

It is not that Brier believes that non-physician managers can’t talk to doctors. . . After all, she herself is not an M.D. Yet she runs Maimonides, a top-ranked 700- bed teaching hospital in Brooklyn, New York.

On the other hand, Brier is not an MBA either. She has a master’s in Health Administration, which means that, unlike many hospital CEOs who went to graduate school to study business, she understands that an organization that provides health care is not a “business” in any ordinary sense of the word. A hospital is a service organization: its raison d’etre is to meet the needs of a community and its patients.

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Below, an excerpt from a superb post by Bob Wachter, Associate Chairman of the Department of Medicine at the University of California, San Francisco, that was originally published on Wachte'r's World. There, he questions whether academic medical centers (AMCs) will be able to turn themselves into the accountable care organizations (ACOs) that reform legislation favors. Or as Wachter, puts it: "Are Academic  Medical Centers Toast in a Post-Healthcare Reform World?”

I believe that some AMCs will be able to “re-vision” themselves, and that this will be the best thing that ever happened to them. Many AMCs need to re-set their priorities, putting less emphasis on money-driven research, while focusing more of  their resources on safe, patient-centered care. As  Wachter,observes, this will mean changing the keenly competitive and often wasteful medical culture traditional at many AMCs.

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U.S. healthcare is awash in medical technology, and recently, in an editorial published on Bloomberg.com, one surgeon suggested that we may be drowning. For as Dr. Craig D. Turner, a urologist in Portland, Oregon points out “what is different with the new wave of technological marvels is that many are heavily driven by marketing; here he links to an ad by GE Health touting wide-bore MRIs “Simply Powerful, Powerfully Simple.”

New technology always poses risks, he points out, because it “requires that physicians master arduous new skills” which means that while doctors climb a steep learning curve, some patients may be hurt.  Someone has to be one of the first hundred patients a doctor learns on. Meanwhile, often, the new, new thing “lacks clear benefits compared with established and less-costly technology.”

Innovation is proceeding at a pace that helps drive waste: “One health-care administrator told me the basement of the hospital is full of million-dollar machines collecting dust — not because they didn’t work or because they were ineffective, but because they have been displaced by newer technology.”
“Now 10 years into surgical practice, I have learned some hard lessons related to new technologies,” Turner admits. “Patients often are put at greater risk as we physicians scale the learning curve. . . More things can go wrong.”

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Below an excerpt from an essay by Dr. Nortin Hadlerprofessor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill, and an attending rheumatologist at University of North Carolina Hospitals. He is the author of "Worried Sick: A Prescription for Health in an Overtreated America," "The Last Well Person," and “Stabbed in the Back.”

I am always delighted when Hadler contributes to HealthBeat. He is willing to tell the truth about medical evidence and comparative effectiveness research– even when candor may not be popular. You don’t have to agree with him, but without question, you should read his work.   Hadler is not a pundit offering one man’s opinion:  his writing is studded with footnotes and links to rigorous medical research.

This post is excerpted from a piece which originally appeared on ABC.com, Health Care Reform: The Difference Between Rationing and Rational.“There  Hadler explains why, if a doctor recommends angioplasty, you should ask some questions. At the end of the post, you will find my “Note” on what I find the most intriguing aspect of Hadler’s essay: how to win the healthcare lottery without buying a ticket.

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Below, another provocative story from Pulse–voices from the heart of medicine, an online magazine of personal experience in health care.  The piece raised some questions in my mind about how we train medical students. You’ll find my comments at the end. (To join the Pulse community, and receive every issue, online, at no cost, click here.)

First, Do No Harm

By Alison Block

It's one of my earliest memories: I'm wrestling with my brother, and I'm losing, because I'm five and he's seven, and he's bigger and stronger than I am. So I bite him, hard.

Instantly I know I've crossed some sort of line, and I employ my most primitive defense mechanism, shouting out, "He bit me! Jon bit me!" I feel shame, because I am old enough to know it is wrong to hurt people–and to lie.

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