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An Easy (But Politically Complicated) Way To Save Billions Of Dollars On Medical Care

Photo credit: KAREN BLEIER/AFP/Getty Images

Photo credit: KAREN BLEIER/AFP/Getty Images

I sometimes worry that my wife Paula won’t be able to see me grow old. Not that I expect to outlive her. She is four years my junior and has the blood pressure of a 17-year-old track star. It’s her eyesight I’m worried about, because she is at risk for a form of blindness called macular degeneration. Paula is the youngest in a long line of redheads, several of whom have been diagnosed with this illness. Her fair-haired grandmother developed macular degeneration and was eventually unable to see her bridge hand and had to give up her golf game, just when she was threatening to score below her age. Fortunately, Paula should be able to avoid her grandmother’s fate, because we now have outstanding treatments for this disease.

Too bad these treatments are costing us billions more than they should. The price of some macular degeneration treatments is staggeringly high, and both doctors and the pharmaceutical company making the treatments are motivated to keep it that way. If we as a country want to forestall blindness in people like my wife, without going bankrupt in the process, we need to pressure our government to do some hardball negotiating.

By way of background, my grandmother-in-law suffered from what ophthalmologists call “wet” macular degeneration. Frail little blood vessels began proliferating in the back of her retina. It’s not unusual to have lots of blood vessels back in the retina. It’s that red blood, after all, that causes so many of us to look possessed in family photos, with red eyes staring demonically into the lens. But in wet macular degeneration, there’s even more blood vessels than normal in the back of the eye, and they are more inclined to leak than typical blood vessels. This leaking fluid damages the nerve cells we depend upon to see light and darkness. For years, there was little doctors could do to slow these leaks.

Then along came Avastin.

Some of you may recognize Avastin as being a cancer drug. That’s true. Avastin works by disrupting a chemical our body makes to promote blood vessel growth. Tumors that depend on new blood vessels to grow are thereby thwarted by the drug. So, too, is macular degeneration. No new frail blood vessels means no blood vessel leakage!

Many ophthalmologists treat wet macular degeneration by injecting Avastin directly into the back of patient’s eyeballs. (Under local anesthesia, of course!) And the drug isn’t even terribly expensive. By one estimate, Medicare pays about $50 a pop for monthly Avastin injections. There is a problem with this effective and affordable treatment, however. Avastin has never been approved by the FDA to treat macular degeneration. Physicians are allowed to use it as an off-label treatment, but because it is off label, it needs to be reformulated by pharmacies into an injectable form, and before standards for such reformulation were bolstered, some patients experienced eye infections from contaminated vials.

Fortunately, there is a second drug to treat macular degeneration, one very similar in its chemical composition, another blood vessel-blocking drug called Lucentis. Unlike Avastin, Lucentis is FDA-approved to treat the disease. That means it is made by the manufacturer in a ready-to-inject formulation, and there is no need for pharmacies to do any additional prepping. Lucentis is just as good as slowing the progression of macular degeneration as Avastin. There’s just one little problem with Lucentis, however. Instead of costing Medicare $50 per pop, it costs up to $2,000.

To read the rest of this article, please visit Forbes.

 

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Specialty Drugs at Especially High Prices

There have been many wonderful new medications in the past decade or so, drugs that finally bring hope for many people with serious illnesses like rheumatoid arthritis, multiple sclerosis and even some advanced cancers. But these drugs often come at a high price. Here is a snapshot of drug spending in 2014, courtesy of the Kaiser Family Foundation:

Kaiser Family Foundation

Kaiser Family Foundation

 

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Peer Comparison Can Reduce Antibiotic Prescribing

Very interesting article in the Lancet recently, from the nudge unit in the United Kingdom. They give physicians feedback on how much they prescribed antibiotics compared to their peers, and found that such feedback reduced antibiotic prescriptions.

Peer Comparison Can Reduce Antibiotic Prescribing

I hope to see more of this work!

 

 

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Sexual Harassment in the Medical Profession

Photo Credit: masterfile.com

Photo Credit: masterfile.com

Here is a report from a study I collaborated on, led by the amazing Reshma Jagsi, a physician at the University of Michigan. It reveals just how common it is for female academic physicians to report experiencing sexual harassment in the workplace. Important but disturbing news:

“This is a sobering reminder that our society has a long way to go before we achieve gender equity,” says study author Reshma Jagsi, M.D., D.Phil., associate professor and deputy chair of radiation oncology at the University of Michigan Medical School.

Researchers surveyed 1,066 men and women who had received a career development award between 2006-2009 from the National Institutes of Health. These awards are given to promising physician-scientists to develop their career as independent investigators. The physicians are now mid-career; average age when surveyed was 43.

Physicians were asked a number of questions about their career experiences, including questions about gender bias, gender advantage and sexual harassment.

Women were more likely than men to report both perceptions and experiences with gender bias: 70 percent of women vs. 22 percent of men perceived gender bias, and 66 percent of women vs. 10 percent of men said they experienced gender bias.

In addition, 30 percent of women compared to 4 percent of men said they had experienced sexual harassment in their professional careers.

To read the rest of this article, please visit Science Daily.

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Here’s Why Insulin Is So Expensive, And How To Reduce Its Price

She drew the life-saving medication into the syringe, just 10cc of colorless fluid for the everyday low price of, gulp, several hundred dollars. Was that a new chemotherapy, specially designed for her tumor? Was it a “specialty drug,” to treat her multiple sclerosis? Nope. It was insulin, a drug that has been around for decades.

The price of many drugs has been on the rise of late, not just new drugs but many that have been in use for many years. Even the price of some generic drugs is on the rise. In some cases, prices are rising because the number of companies making specific drugs has declined, until there is only one manufacturer left in the market, leading to monopolistic pricing. In other cases, companies have run into problems with their manufacturing processes, causing unexpected shortages. And in infamous cases, greedy CEOs have hiked prices figuring that desperate patients would have little choice but to purchase their products.

Then there’s the case of insulin. No monopoly issue here – three companies manufacturer insulin in the U.S., not a robust marketplace, but one, it would seem, that should put pressure on producers. No major manufacturing problems, either. There has been a steady supply of insulin on the market for more than a half century. And there haven’t been any insulin company executives I know of who have been hustled in front of grand juries lately.

Yet insulin prices are rising to dizzying heights. In 1991, according to a recent study inJAMA, state Medicaid programs typically paid less than $4 for a unit of rapid acting insulin. After accounting for inflation, that price has quintupled in the meantime.

What explains the gravity-defying cost of insulin? I am not an expert on pharmaceutical pricing, but a few factors go a long way to explaining insulin prices. First, the insulin marketplace has been characterized by continual product upgrades. You see, there’s not just one chemical that makes up all insulin products. Instead, insulin treatments are a family of products, each with slightly different chemical makeup that influences things like how quickly the medicine is absorbed into the blood stream. Manufacturers have been toying with insulin molecules since at least 1936, when the manufacturer added protamine to insulin molecules to extend the duration of the chemical’s activity. In the 1960s, companies began synthesizing insulin, rather than harvesting it from pancreatic tissue. In the late 70s, they began producing insulin through genetic engineering.

So when I said that the price of insulin had quintupled over the decades, we have to keep in mind that today’s insulin is not the same as yesterday’s.

(To read the rest of this article, please visit Forbes.)

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See Mom, I CAN Teach!

Photo Credit: chapel.duke.edu

Photo Credit: chapel.duke.edu

I got a really nice email the other day, from one of the provosts at my university. Here is the highlight:

“During the 2015 fall semester, in the categories of Quality of Course and/or Intellectual Stimulation, your course evaluations were among the top 5% of all undergraduate instructors at Duke.”

Which just leaves one question: Was it the quality of the course or the intellectual stimulation? Given the intellectual depths to which I normally climb, I’m betting on course quality!

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Should You Want a Robot to Do Your Surgery?

Photo credit: urology.osu.edu

Photo credit: urology.osu.edu

Karen Scherr, an MD PhD student working with me, just published a paper showing that physicians don’t always give patients objective advice about the pros and cons of robotic surgery. Here is a news story on her work:

Duke University research found that doctors are more enthusiastic about treatments that are readily available, calling into question whether the doctors are recommending the best treatment, or just the one more readily available.

“Patients need accurate and unbiased information about their treatment choices, regardless of what is available where their appointment is taking place,” said Fuqua School of Business Professor Peter Ubel. “It’s the only way they can make fully informed decisions.”

Ubel’s research, published in the journal Health Communications found that robotic surgery was described in more positive terms to prostate cancer patients at hospitals where it was available than at facilities where it was not.

Importantly, the research looked at four Veterans Affairs medical centers. Because VA physicians are salaried employees, the researchers could rule out financial incentives as a factor in how the treatments were described. Other research has linked surgeons with procedures on which they could gain financially, so ruling that out bolsters the findings.

Although researchers found a correlation, they didn’t immediately draw a conclusion of nefarious activity among doctors. Instead, they drew a different conclusion.

“We found that physicians describe robotic prostatectomy more positively when it’s available,” said Karen Scherr, a Duke M.D./Ph.D. student who helped with the research. “Importantly, this seems to be happening because of concern about patients’ emotions when they find robotic surgery isn’t available. I don’t think physicians are doing this for any malicious reason. It’s just very difficult to tell people about something good if it’s not available, and if it is available you want to tell people it’s good.”

To read the full article, please visit the Triangle Business Journal.

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The Majority of Doctors in the Majority of Specialties – Are Experiencing Burnout

And the problem is getting worse with time!

The Majority of Doctors in the Majority of Specialties Are Experiencing Burnout

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Doctor Knows Best?

Peter Ubel Sport Coat

Photo Credit: NIH

Here is a write-up of a talk I recently gave at the NIH. The topic is a good one, about doctors and decision making and all that crap. But the real importance of linking you to the story is to find out if you hate my sport coat as much as my wife does. It is the only one I own now, and I’ve had it for 25+ years. Time for a new one?

Does doctor always know best? Patients often ask their doctor: “What would you do in my situation?” But as the doctor explains the risks and benefits of treatment options and imparts advice, it’s important to remember there’s a human behind that medical chart, a patient with unique values, opinions and personal preferences.

A doctor’s recommendation often influences a patient’s treatment choice, so the clinician has a huge moral responsibility to recommend well, said Dr. Peter Ubel, a physician and behavioral scientist who teaches public policy and business at Duke University. He led an animated, thought-provoking discussion about shared decision-making among doctors and patients at a bioethics lecture Mar. 22 in Lipsett Amphitheater.

“People want to be heard and understood. That, to me, is what shared decision-making is; that’s what partnership is,” said Ubel, who helps prepare business students for jobs in health care. “What we need to do as clinicians is to get better at eliciting those patient preferences. [Clinicians should tell patients]:‘I’m the expert on medical facts, but you’re the expert on you.’”

Ubel used the example of a patient with low-grade prostate cancer who was trying to decide between surveillance or surgery and radiation. Whether he chose the passive or active approach, the survival rate was the same. But with waiting comes anxiety, and with the medical procedures, he’d run the risk of incontinence and erectile dysfunction.

In this case, how worried was the patient about those side effects? What were his life goals? Asking these kinds of questions can help determine the best course of action. In a similar case, a patient said he preferred the watch-and-wait approach, that he could more easily pursue active treatment after he retired in a couple of years.

“All else equal, the treatment people receive should have something to do with what they care about and these baseline preferences,” said Ubel.

The doctor also should consider the patient’s reaction when delivering the diagnosis, said Ubel. In a urology office, a doctor told a patient he had slow-growing cancer, then tossed out a lot of convoluted, vague information. The doctor may think it’s not an aggressive case so it’s not bad news, but the patient probably only heard, “you’ve got cancer” and tuned out the rest.

People need time to recover from bad news before making an informed decision. Ubel warned that information overload reduces comprehension and retention, and ultimately affects the patient’s choice.

“I think in part because of the way we’re taught in medical school about informed consent and patient autonomy, there’s this big emphasis on information,” said Ubel. “We inform the hell out of patients in jargon they can’t understand at a time when they’re not ready to take on complex information.”

If we have too many choices and too much information to process, Ubel said, people disengage. And patients might just ask for the doctor’s advice without really understanding the diagnosis and treatment alternatives.

“One of the problems with shared decision-making and promoting patient autonomy is that thorough communication is not always good communication,” he said. “Good communication takes time; it takes time to deliver it well and it takes time for the patient to absorb the information.”

In one survey, urologists said they only dispensed advice after gauging which way the patient was leaning. The urologists usually asked whether the patient had normal sexual function, but only 12 percent asked whether sexual function was important to the patient. And, astoundingly, only 13 percent said this preference should factor into deciding the right treatment. Look beyond age and test results, said Ubel; consider what patients care about.

To read the rest of this story, please visit the NIH.

 

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Marketing 101

Brilliant graphic, courtesy of @Brilliant_Ads

Photo Credit: Brilliant Ads

Photo Credit: Brilliant Ads

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