HealthCommentary

Exploring Human Potential

Where will reform come next, and who will lead the way?

Posted on | April 16, 2018 | No Comments

Mike Magee

“On résiste à l’invasion des armées; on ne résiste pas à l’invasion des idées.”  – Victor Hugo.

It’s useful for all health professionals  to reflect on the words of this 19th century French writer. The translation: “Greater than the tread of mighty armies is an idea whose time has come.”

As the AEI chart above illustrates, there is growing collective awareness that our health care system is breaking the bank as it fails to deliver a healthy America while robbing resources from other critical societal needs that contribute to our health and wellbeing.

Hospital cost inflation over the past two decades tops the inflation list above at over 200% with general medical care weighing in at 125%. One in every five dollars consumed by health care today goes to our medical-industrial complex.

Warren Buffett’s assessment that “Medical costs are the tapeworm of American economic competitiveness”  is right on. His critique has focused on data, cost, and level of engagement. We are challenged by the virtual absence of national health planning and a massively inefficient delivery system.

One of the pillars of resistance to addressing the status-quo, the medical establishment, is eroding as we speak. More than half of all physicians are now corporate employees. Teams with “physician extenders”, known by their patients as health professionals, are the standard, not they exception. Physicians sloppy prescribing has ignited the opioid epidemic and exposed them as easy marks for health product marketers. And it’s not just opioids. Witness anti-depressant addiction especially in women over 55 or poly-pharmacy in seniors nationwide.

Quality issues beg for health delivery disruption. Add to this that there is more than enough money in the system were it to be redirected. The centralized standardization of basic benefit packages and billing systems alone would deliver a 15% savings on our $4 trillion plus annual spend right off the block. Centralization is not socialization. Delivery solutions in all developed nations involve public/private solutions executed on a local level.

In our own country,  we are witnessing the emergence of “disruptors.” The current favorite for speculators in the health sector is CVS who has a $69 billion offer to purchase Aetna on the table. In this week’s JAMA, the new Panning Dean of the new Kaiser Permanente School of Medicine, geriatrician and medical ethicist Christine Cassel offered her analysis.

She notes that CVS has 9700 stores nationwide and 1100 attached retail clinics thus far. Leaders of the corporation envision providing “10,000 front doors” to patients of the future.

CVS’s growth in direct care thus far has been based on access and convenience – and sometimes physician choice. For example, when I was due for a shingles vaccine recently, my internest ( who is employed by a corporate health system)  elected to send me to the pharmacist next door rather than spend time (and money) himself.

Another CVS standard is pharmaceutical continuity and delegation of care to non-physicians. Offerings at first were limited, but they are rapidly approaching the offerings of most primary care offices, quite a feat since CVS has made a minimal investment as yet in adequate brick and mortar to house the services. Cost-effectiveness is also a goal with almost all services coming in under $100, and insurers welcome.

CVS has also been making a run at the status-quo with data (They now own a dominant PBM and will soon add a major insurance database). All that’s left is engagement. Specifically, they need to connect to existing health care systems. With Aetna, they may have a running start since the insurer has been active in the Medicare Advantage plans and in Medicaid risk bearing health delivery, both proposed as vehicles for a public march toward universality.

But they needn’t wait for Aetna – and as it turns out, they haven’t. Four years ago, the Advisor Board reported that CVS already had formal relationships with 350 hospitals in addition to clinics and physician groups. In the D.C. area at the time they were integrating their electronic medical records with MedStar Health’s 10 hospitals and 4000 doctors, and promising the system’s patients the future ability to access their medical records at any of the CVS stores nationwide. And it wasn’t just MedStar. At the time CVS had 41 similar health-system agreements formalized. That was four years ago.

But has “the time come” as Victor Hugo professed?

Consider the politics in addition to the financials. For the past two years we have witnessed our worst tribal instincts on full display. In general, America’s goodness has so far survived and appears to be  growing in strength and organization whether it be teens rising up against gun violence, media on hyper-alert as they face off  “fake news” or the independence of our Justice System reinforcing through action that “no one is above the law.”

The 2018 election could create the momentum for a push toward solidarity and a refocus on positive values. If so, at least based on the chart above, health care reform and educational reform will likely lead the way.

“On résiste à l’invasion des armées; on ne résiste pas à l’invasion des idées.”

You Are Your DNA – or Are You???

Posted on | April 10, 2018 | No Comments

Source:
U. of Utah Epigenetics

Mike Magee

Early in my career, embryology and physiology competed for my affection.

What they had in common was functionality – one developmental with time dependent triggers and the other driven by feedback loops with humoral packets of information traveling through blood channels or along neurons.

I viewed both processes as eloquent, intricate, and genomically dependent. But what appeared so concrete to me then, is being challenged by modern science in the name of epigenetics.

The epigenome is nuclear information and is inheritable, but it’s also plastic. It contributes to cellular development and differentiation during embryogenesis, but its’ messaging can be modified by random chance changes or by environmental exposures.

All cells of the body have the same DNA, but they evolve during development assuming specialized functions. How is that possible? The answer is in part that the cells add epigenetic genomic information to their own genes.

The University of Utah’s Epigenetic training site says “The genome is just the A,G,T,C bases that encode proteins and other mRNAmolecules.  The “epi”genome are various modifications to the DNA – such as methylation (at C residues) – and acetylation of histone proteins.   These changes help the DNA form various secondary and tertiary structures that can facilitate or block the interaction of DNA with the transcriptional machinery.”

Conrad Waddington first described the “epigenetic landscape” in 1950 as the evolving specialized development of pluripotential stem cells. The instigators were presumed to be imbedded somehow in the DNA. But a more modern construct suggests that there are modifications and/or additions to the DNA, some driven by environmental factors, and that these modifiers are maintained in future cell divisions.

This not only modifies our view of embryology, but also of the aging process, the dietary impact on health, and the pathogensis of cancer and its metastatic spread.

For example, nicotine instigates epigentic changes in smokers and in cord blood and the placenta.

Almost all tumors have documented gains and losses in their cellular DNA. Where in the past cancer was viewed as many diseases, scientists are now beginning to believe they have more in common than previously thought, and that the essential common feature is a “disrupted and unstable epigenome.”

With wholesale availability of genetic testing, citizens are putting down their money to identify their genetic predisposition to disease. The problem is that this picks up only a very small fraction of ones vulnerability, failing to capture the role of the environment which scientists are now saying may account for 80% of ones disease risk.
Inflammation, diet, toxins and more deliver their destructive punch through an interaction between genes and the environment, and epigenetics – whose chemistry is now being structurally defined – likely mediates these destructive changes, as well as potential new therapies.

U.Utah Epigenetics

Finally the issue of epigentics and inheritabilty. The Utah experts suggest, “The sketch … tries to explain why epigenetic effects can, in practice, be difficult to disentangle from true (changes in the A,G,T,C sequence) genetic effects.  This is because – for one reason – a mother’s experience (extreme stress, malnutrition, chemical toxins) can – based on some evidence – exert an effect on the methylation of her child’s genome… if the daughter’s behavior or physiology were to be influenced by such methylation, then she could, in theory, when reaching reproductive age, expose her developing child to an environment that leads to altered methylation (shown here of the grandaughter’s genome).  Thus, an epigenetic change would look much like there is a genetic variant being passed from one generation to the next, but such a genetic variant need not exist – as it is an epigenetic phenomenon.”

So, are you really your DNA, or something more? Stay tuned!

DACA and the Health Benefits of a “Shot at Upward Mobility”.

Posted on | April 6, 2018 | No Comments

Mike Magee

A recent paper from the National Bureau of Economic Research, reported out in The Atlantic, began with the health outcomes in DACA children but ended with thoughts on why a teenage girl in Mississippi is 15 times more likely to give birth than her counterpart in Switzerland.

DACA is a favorite topic of President Trump along with claims of immigrant hordes and the scourges of NAFTA. Deferred Action for Childhood Arrivals (DACA) is an Obama initiative that shielded 1.3 million children who arrived initially with their illegal immigrant parents, and who then stayed and worked legally in the U.S. The legislation allowed registration and subsequent protection from deportation for renewable 2-year periods.

The success of the program was highly dependent on these vulnerable individuals trusting their government, and believing it would not subsequently turn on them once they came in from the shadows and exposed themselves thru registration. As is clear now, that is exactly what Trump attempted to do. Up till now court rulings have checked his predatory instincts.

The NBER paper makes the point that the elimination of DACA would not only be a remarkably callous and unethical move, but it would also have significant negative health consequences.

It turns out that DACA kids have been doing quite well since Obama set them free. High school graduation (a requirement of DACA) has increased 15%, college attendance is up 25%, and teen births have declined 45%.

What’s most interesting about these results is what they tell us about the relationship between optimism and health outcomes. These authors and others in the field believe that hope for the future ignites course corrections in teens. They see the future though different glasses. Their education, work/study jobs, drivers licenses, and lower stress, combined with the promise of higher wages in the future, lead to less high-risk behavior in the present.

Multiple prior studies have suggested that the option of pregnancy for a teen is often an active choice when other options for a promising future are removed. Teen pregnancies and births outside of marriage track with advancing income inequality.

Mississippi is Mississippi and not Switzerland when it comes to life expectancy for mothers and babies as much because of hopelessness as anything else. There is a price to be paid each day, for DACA kids and each and every American, for a culture absent universality and solidarity. Health breeds wider choices and better futures. #2018 elections.

 

What Uwe Reinhardt (or Angus Deaton) Would Say About HC Costs.

Posted on | March 19, 2018 | No Comments

Mike Magee

A March 13, 2018 article written by scholars from the London School of Economics and published in JAMA focused on an all too familiar subject – comparative health care costs in America. That article was accompanied by a number of editorial reaction pieces including the one written by Zeke Emanuel who generated the comparative pricing chart below.

In general, most all agree that the facts suggest that in four areas – drugs, high volume/high margin interventional procedures, radiologic imaging tests, and administrative costs – the U.S. is financially out of whack. Other commentators placed a spotlight on our encouragement of “monopolists” in pursuit of “innovation”, and our reckless spending priorities at the beginning and end of life.

In return we have the dubious distinction of generating 57% of new chemical entities, at least some of which add little extra and have been advanced through DTC ad-driven market expansion with the tacit support of remarkably gullible over-prescribing physicians. And of course those new “Right-to-Try” policy shifts advocated by Trump should just add to our “American exceptionalism” in health.

One editorial written by two JAMA editors was entitled “What Uwe Reinhardt Might Have Said.” The much revered Princeton health economist who recently died was known for not pulling punches. In one analysis of our private health insurers, he documented that 18 cents on every insurer’s dollar was spent on “operations” which included “marketing, determining eligibility, utilization controls (eg, prior authorization of particular procedures), claims processing, and negotiating fees with each and every physician, hospital, and other health care workers and facilities.” All of this, he charged, proceeds within a “shroud of secrecy.”

Were he to be alive, the JAMA editors predicted he might have commented on “the many self-interested parties, including professional societies, patient groups, hospitals, drug and device manufacturers, and insurance companies, that profit from high health care spending.” Noting that Reinhardt often would initiate a comment with the phrase, “You Americans”, the editors offered two probing questions he might have posed:

1. “How can the US health care system and health care spending be recalibrated to ensure basic care for all US residents, particularly the less fortunate?”

2. “How is it possible to overcome the shortchanging of many other important sectors of society, including education, infrastructure, and the environment, because of the high cost of health care?”

Such comments only gently scratch the surface of the Medical-Industrial Complex’s full culpability. Were Reinhardt still alive, he would have done well to illustrate his legitimate points with the case study first exposed by his Princeton colleague, Angus Deaton. The still raging opioid epidemic demonstrates how far astray a health care system can wander when based on profit and greed rather than on planning and prevention; and how the leaders of Medicine, including those who own JAMA, played a critical role in igniting this disaster which continues to divert precious resources as it claims more and more American lives.

To my knowledge, they have never acknowledged or apologized for their institutional role in legitimizing Purdue-Pharma funded specialty pain societies; provided an advertising vehicle for their product, Oxycontin; and willingly enabled Purdue Pharma’s soft target, data driven physician prescription profiling through sales of their physician masterfile database.

How Trump May Help Us Liberalize American Health.

Posted on | March 17, 2018 | No Comments

Mike Magee

In this week’s The New Yorker, David Remnick reflects on “Trump’s illiberalism” and its’ test of the resilience of  “sturdy-seeming American values” and the endurance of  “institutions that the President has scorned and threatened.”

He sees active turnout in the 2018 midterm elections as part of the test, but also suggests that any victory here will require more to follow, namely “an honest, complex, open-minded debate on immigration, income disparity, distrust of government, guns, race, gender, speech, social media, and the environment.”

And what of health? That was my first reaction to his list, followed instanteously by my mind’s response, “Well, health underpins them all, doesn’t it?” And of course, the answer is yes. A decade ago, I laid out seven principles that attempted to respond to the question, “How do we make America healthy again?”

The seven visions were:

1. Health is political.

2. Reconnecting the family.

3. Lifespan Planning.

4. Home-centered health care.

5. Integrating health databases.

6. Techmanity: Humanizing technology.

7. Caring for the “planetary patient.”

Since then, Health Commentary has touched on these “liberal arts” themes again and again, reinforcing principles and tracking our evolution, often proceeding at a slower pace than I had predicted. Hcom has highlighted the economic perspective as well, which only adds to the sense of national urgency.

Remnick’s point is that the Trumpian crisis has liberal benefits – to test, to challenge, to motivate, to activate, and to accelerate. A healthy America welcomes new entrants, embraces diversity, leads in the public sphere, exposes and addresses prejudice wherever and whenever it occurs, limits guns and violence, encourages respectful communications, and rises to the environmental challenge.

A healthy America requires healthy Americans. We need to get on with it. Enough time has passed for us to rise to the challenge. #2018 Election.

Hospital Obsolescence or Hospital Reinvention?

Posted on | March 8, 2018 | No Comments

Mike Magee

Two weeks ago Zeke Emanuel asked the question “Are hospitals becoming obsolete?” In his New York Times Op-Ed he flagged the high water mark for the industry as 1981, a year when 6,933 hospitals nationwide admitted 39 million patients or 171 for every 1000 Americans. Thirty five years later, our population has grown 40%, and numbers of hospitals have declined by 20%, with those remaining functioning at 65% occupancy rates.

The industry consumes roughly a third of our national health care spend at $1.1 trillion. And all the while we’re treated to scandalous stories like the one in the Washington Post this past October titled “A hospital threw a still born out with dirty laundry.” The 98,000 deaths attributed to hospital error in 1999 have now grown by some estimates to 440,000. And as whipsawed hospital CEO’s like Geisinger’s David Fineberg recently proclaimed, “We should be investing in people and processes, not hospitals.”

Having spent a few years running hospitals myself, I understand the challenges and complexity. They play a critical stabilizing role in their communities, have a mixed governance model that can be confusing, struggle with continuously aging brick and mortar, support 24/7 coverage expectations, deal with incessant demands for expensive technology, and maintain complex, diverse workforces.

Health care is the largest employer in America, and labor accounts for half the total cost of health service delivery in the U.S. But increasingly the workforce is clerical with 16 positions for every one physician, and half of those 16 being non-clinical. They are also flowing outpatient and home-based where, according to Johns Hopkins geriatrician, Bruce Leff, care for some conditions normally treated in hospitals can now be accomplished at home with a 30% to 50% savings and many fewer complications.

Leff predicts hospitals like his will soon morph into “large intensive care units” or (like Columbia Presbyterian) become indistinguishable from corporate research enterprises on the prowl for NIH grants and pots of patent gold. Of course, training primary care doctors in academic centers like these has been recognized as problematic for some time. So as care moves outpatient, primary care training will need to as well.

Hospitals like New York’s Mount Sinai have moved vertically downstream establishing their own hospital-at-home product called “HaH-plus”. Their mobile acute care team thinks they can save Medicare money, and that as many as a half million Medicare patients could qualify at a savings of 20% for Medicare.

Other hospitals are done with massive edifices and instead are building two or three story “healthplex” complexes following the lead of the hotel industry that has gone boutique and in a short two decades created easy to use, low cost lodging options with a skinny labor profile.  The new skinny hospital menu of services will likely include emergency care, labor&delivery, some surgery, lab and radiology.

Repurposing old hospitals with their wide hallways and broad walled rooms has been problematic all along. Not only are they difficult to redesign, but their outmoded HVAC, poor access, and disintegrating construction often beg for dismantling. Some – like the old factories they resemble – do survive for mental health services, addiction services, and a range of local governmental uses.

But in the end form must follow function. And demographic changes, technologic progress, and the proven risks of being a traditional hospital in-patient in the modern age suggest evolving functionality with more mobile, segregated, targeted and personalized forms of care will dominate the immediate hospital horizon.

The Basics of Pharma Kickbacks – Opaque & Complex

Posted on | March 7, 2018 | 2 Comments

Mike Magee

With great fanfare, the New York Times announced this week that UnitedHealthcare   “would stop keeping millions of dollars in discounts it gets from drug companies and share them with its customers.” For awhile, pharma, insurers, pharmacies and PBMs have been pointing fingers at each other over escalating costs. That’s become more difficult of late with vertical integration moves from the likes of CVS and United Healthcare which not only own PBMs, but are also providing direct health services.

Former Lilly exec and new head of HHS, Alex Azar, applauded the move as “a prime example of the type of movement toward transparency and lower drug prices for millions of patients that the Trump administration is championing.” But in reality the move was defensive and will benefit only a small number of UnitedHealth Group patients.

The system outlined above in quick scribble is a complex exercise in backscratching, legal pay off’s, and inefficiency that proves the old adage that “one man’s waste is another man’s wealth.”

The flow of pills depicted above is pretty straight forward: From manufacturer to wholesale middlemen to pharmacies to us. But the flow of money is anything but straightforward. Three decades ago Merck purchased the Pharmacy Benefit Manager Medco which eventually became so profitable it overshadowed Merck.

PBMs are now the Grand Central Station of legal drug money and data transfers. They negotiate the deals for each and every drug with pharma, placement of those drugs on insurers tiered insurer lists, and integrate the data with pharmacies and insurers nationwide. Their cut-outs and give-backs are non-transparent, and nearly everyone is in on the deal – except you.

After you chose your pharmacy plan and pay your bill, money flows from you (in the form of deductibles and co-pays), to the pharmacy, who paid the wholesaler, who paid the drug company. But the payments don’t end there. The insurer gets kick-backs from the drug companies and PBM’s in thanks for choosing the preferred product, and the PBM keeps track of your insurance profile and money transfers to your pharmacy as efficently as Western Union – for a price, of course.

It’s confusing – and its big, very big. Here are a few numbers:

  1. Quantity: 4 1/2 billion prescriptions filled each year – 90% generic.

 

  1. Consumption: 50% filled 1 prescription in the past 30 days – 10% on 5+ prescription drugs.

 

  1. Construction: Majority of raw materials produced overseas by a $46 billion dollar manufacturing conclave.

 

  1. First stop – Wholesalers: 85% go through one of three middlemen – AmerisourceBergen, Cardinal Health, and McKesson – a $400 billion + cost to Americans.

 

  1. Retail: 60,000 pharmacies collect about $365 billion in revenue a year. Chains control 74% of all retail income – 62% in person and 38% by mail order.

 

  1. Who Pays?: Ultimately, we do! Along the way, almost everybody, but us,  gets a kickback.

 

  1. What about Insurers? 86% of drug bill is paid by insurers – but they are paying with your premium dollars, and kickback dollars from drug companies and PBMs.

 

  1. Cost Control: Insurers use PBMs to hold down their costs. They create the tiered drug coverage plans, negotiate prices with drug companies, and manage the computer payment systems. The top three are owned by CVS (CVS Caremark), UnitedHealth Group (UnitedHealthOptum), and a mail order pharmacy (Express Scripts).

Free enterprise loves complexity. Why? It’s hard to read, harder to dismantle, and adds profit every step along the way. Case in point – Cigna’s $67 billion dollar offer this week to buy ExpressScripts, the nation’s largest PBM. Cigna CEO David Cordani laid out his reasoning in black and white.

“When we think about Express Scripts, it has PBM capabilities, but it has 27,000 individuals and a significant number of consumer touchpoints around health and well being. It expands our service portfolio beyond that of a PBM. Having the capabilities to serve an individual whether they are healthy, healthy at risk, chronic or acute is important.”

 

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