ACP Internist Blog

Friday, December 7, 2018

Yes, price matters

Two articles in the New York Times health section today reinforce a major message from a recent Annals On Call: Oral Pharmacologic Therapy in Type 2 Diabetes: Choosing Therapy Wisely (Podcast with Dr. Mike Barry)—price matters.

The first article, “Amgen Slashes the Price of a Promising Cholesterol Drug“ refers to their PCSK9 inhibitor.

For years, the drug maker Amgen has struggled to sell its new anti-cholesterol drug, Repatha after insurers balked over the list price of about $14,000 a year.
On Wednesday, Amgen took a new approach: It said it would slash the list price to $5,850 a year in hopes of increasing sales, especially among Medicare beneficiaries who are particularly vulnerable to a drug's list price.

Yesterday President Trump proposed an interesting strategy to decrease the prices that Medicare pays to pharmaceutical companies, in the article “Trump Proposes to Lower Drug Prices by Basing Them on Other Countries' Costs“.

Mr. Trump's announcement came a few hours after his administration released a government study that said Medicare was paying 80% more than other advanced industrial countries for some of the most costly physician-administered medicines.
“The current international drug-pricing system has put America in last place,” Alex M. Azar II, the Secretary of Health and Human Services, said in unveiling the report.
Mr. Trump cited the government's international drug-pricing report in his speech on Thursday, saying he was taking aim at “global free riding” that forces Americans to subsidize drug prices in other countries.
“Americans pay more so that other countries can pay less,” Mr. Trump said.
The report compares prices charged by drug manufacturers in the United States and 16 other countries for 27 drugs that are covered by Part B of Medicare.

The proposed plan:

President Trump proposed on Thursday that Medicare pay for certain prescription drugs based on the prices paid in other advanced industrial countries, a huge change that could save money for the government and for millions of Medicare beneficiaries.
As part of a demonstration project covering half the country, Medicare would establish an ”international pricing index” and use it as a benchmark in deciding how much to pay for drugs covered by Part B of Medicare.

While we have to see more details, the concept seems admirable. Why should we pay more for the same drugs than countries like Germany, England, France, etc.?

Previous proposals have suggested allowing Medicare to negotiate prices. This idea has not gathered enough support previously. The international pricing index idea at face value sounds promising. Of course, we have to await more details.

But the big point is that price matters. In economic terms, recent expensive drugs have demonstrated elasticity. Elasticity means that as prices increase the volume of sales decreases.

We want progress in drug development. We have many exciting new therapeutic approaches. But price does matter. Perhaps Trump's proposal we garner enough data to make pricing more fair for our country. One can only hope.

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.
Thursday, December 6, 2018

What physicians can learn from politicians

Shock. Horror. Did you just read the title correctly, or are you seeing things? Well, after you recover from the shock of reading a line you probably never thought you could possibly see in writing, let me tell you this: physicians and politicians are probably as opposite as you can imagine in terms of their daily work life, guiding principles, and yes—level of respect shown to them by the general public. Doctors dedicate their careers to helping people and like to pride themselves on always being models of honesty and high morality. Politicians, well, I'll let you decide.

Election days are a special day for American democracy, when we all get to exercise our right to vote and choose our elected representatives, I thought this would be an appropriate topic. It's easy to take our freedoms today for granted, and forget how long of a journey mankind has been on to get to this point. Democracy is to be cherished. It may have its drawbacks and be imperfect, but we do need politicians and people who stand up to make tough decisions. The alternative is too dark to contemplate. Winston Churchill once said: “Democracy is the worst form of government, except for all the others.” That's a very true statement.

There are some bad politicians out there, and some reasonably good ones, likely dependent on your own worldview. Successful ones however, have succeeded in large part because of their savviness and ability to communicate. Here are three lessons that may be relevant for physicians:

1. Keep the message short and simple
Doctors, being scientists at heart, frequently communicate in over-complicated technical jargon when they talk to patients. They forget that most people out there (even otherwise highly educated folk) are not familiar with most of the everyday medical lingo we use. I've seen highly experienced and well-recognized physicians, have some pretty shocking conversations with patients and their families! They mean well, but just forget to keep things simple. Successful politicians understand that whatever angle you are coming from, human understanding on important topics is best reinforced by very simple and straightforward messages. People also have short attention spans in general. Oh, and catchy soundbites totally do work, whether we admit it or not.

2. Use emotions in the right way
Human beings are highly emotional animals. Politicians unfortunately frequently play into this in the wrong way for the benefit of their own ambitions. But keeping this in mind, emotions can actually be harnessed for tremendously positive effect as well. Whether it's reinforcing a reason why weight loss needs to occur for their own health, why they need to take their medicines on time, or the absolute necessity of following up with you in one week, there is an effective and sensitive way to do this.

3. Know that you are always on stage and your words matter
Politicians know that when they step out in public or go on camera, everything about them is going to be analyzed. Every single word, their body language, and what they wear. Their language is going to reverberate across the country and perhaps all over the world too, depending on how important they are. How many doctors have this level of self-awareness too? We are actually viewed as leaders in our hospitals and clinics at all times, even if we don't have any other title beyond MD. From the housekeeping staff to the cafeteria cashier—our fellow professionals know that we are the people who make the final call in clinical situations. The buck stops with us. We owe it to everyone to be aware of this and strive to be role models.

I hope you have recovered from the shock of the title by now. It's a privilege to be a physician, despite all the challenges we face in health care. There are few more important jobs to society, and when we make it all about our patients, there is never a wasted moment. Rarely can we ever come home feeling like we haven't done anything meaningful with our day.

And going back to politics, it's a privilege to live in a peaceful democracy and free country. Sadly something too much of the world still can't say in 2018. I hope no matter what your political point of view, whatever issues are driving you, you exercise your right to vote.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.

Financial security of health care

With the midterm elections in the rear view mirror, and a divided government coming, there has been a lot of speculation that the most likely outcome would be a grinding stalemate in Washington. So I was surprised when I saw a headline in the New York Times last week that speculated that progress in Congress was still likely on a number of important personal finance issues. When I read past the headline, however, what really struck me was that so many of the issues they reported on were really not about personal finance, so much as about how the crazy state of health care in America is a financial nightmare for so many.

The authors cited six areas where Congress could still get its act together and pass meaningful reform despite the partisan rancor:
• better data on college graduate earnings,
• reasonable accommodations for pregnant workers,
• expanded tax breaks for paid family or medical leave,
• expansion of medical expense tax deductions,
• elimination of surprise medical bills, and
• curbs on black marks from medical debt.

Forget about the policy details for a minute and just look at the list. Five of the six items that need fixing are all about health care. More to the point, they are about how the current health care system leaves so many Americans one health crisis (or pregnancy!) away from financial ruination, and about the blindingly complex way that care is financed in the U.S.

People have to worry about accommodation for pregnancy or illness because we lack a national commitment to health. We need higher deductions for medical expenses because the expenses are so high that they cause widespread hardship. We need protection from surprise medical bills because there is too little transparency and too much complexity in health care coverage. And it is nothing less than a national stain that the most prevalent cause of personal bankruptcy is medical expense. We don't need fewer “black marks” on our credit ratings from medical debt, we need less medical debt.

This is a list that would make no sense to citizens of just about every other country with an advanced industrialized economy.

I think this list is just one more sign that we are on an unsustainable path, and—divided government or not—some serious reform of health care financing has to come soon.

What do you think?

Ira S. Nash, MD, FACP, is the senior vice president and executive director of Northwell Health Physician Partners, and a professor of cardiology and professor of occupational medicine, epidemiology, and prevention at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. He is board certified in internal medicine and cardiovascular diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining Northwell Health. He is married with two daughters and enjoys cars, reading biographies, and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.
Monday, December 3, 2018

Ruptured plantar fascia

Many people have experienced plantar fasciitis. It is a painful bottom (plantar surface) of the foot that often comes on after athletic exercise, prolonged hiking or running or just for no reason at all.

The plantar fascia is a band of tissue that connects the heel bone to the toes. This wide ligament covers the entire bottom of the foot and acts like an elastic band under the arch and helps absorb shock when you walk. Inflammation and tiny micro tears are the culprit in plantar fasciitis. Most patients can diagnose it themselves and it rarely needs imaging or any special tests.

Ruptured plantar fascia is relatively rare and the snap occurs suddenly, usually with exercise. The force of jumping or stepping can cause a tear that causes sudden pain and inability to bear weight on that foot. The injured athlete often feels a “pop” when the fascia snaps. Within 24 hours the blood from the tear forms a bruise on the bottom of the foot.

So what should be done for a torn plantar fascia? Like any muscular injury, ice is the first treatment. It not only limits further bleeding and swelling, it also provides pain relief. Elevation and compression (ace wrap) are also first treatments. An ultrasound is usually as effective as an MRI for seeing the ligament but the diagnosis does not require any imaging. Physical therapy and using a walking boot are helpful for the first few weeks of healing. It is very rare that surgery is needed. The fascia forms a scar and heals itself. Sometimes shoe orthotics are used to support the arch during healing.

The best way to keep your feet healthy and prevent plantar injuries are:
• weight control,
• never get a steroid injection into the plantar fascia (it is a risk factor for rupture),
• stretching the toes and feet before activity,
• stretch the arch of your feet,
• stretch the Achilles tendon (it's all connected),
• wear good athletic and walking shoes with arch support,
• use heel cups or shoe inserts (over the counter is fine), and
• flex your feet/toes upward when you are in bed and before you get up in the morning.

This post originally appeared at Everything Health. Toni Brayer, MD, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.