Time: Bitter Pill: Why Medical Bills Are Killing Us

[SkinsHokieFan]

Not enough attention drawn to the negative effects of prescription drugs, particularly their interactions.

I agree. They are a disaster in my opinion.

The last few years of my dad's life were a cocktail of prescription drugs, blood pressure drugs, blood thinner drugs, etc, etc.

Really had he changed his eating habits 10-15 years ago, he probably would have been fine

[Corcaigh]

There seems to be a pervasive view in the medical profession that most of their patients are lazy (probably correct ) and will not fix problems that could be addressed through diet and exercise, so the patient gets a cocktail of crap with nasty side effects to take for the rest of their lives.

The common reaction that runners get in a check up when the doc measures a resting pulse in the 50s, and fantastic numbers for cholesterol and blood pressure, is that the patient is some kind of freak and curiosity of what motivates people to be healthy like that. Was there a trauma experienced earlier in life?

Anyway, I don't think prescription drugs are what's causing out of control healthcare, but it contributes. And patients typically don't seem to be presented with the idea that taking all these drugs is really bad for them. It's better than doing nothing. But those aren't the only choices and often they are presented as such because the healthcare system rewards transactions, not patient health.

Before you get in your car to visit the drive-though for your super sized Big Mac and large fries, remember to take your cholesterol and blood pressure medication.

[PeterMP]

This takes 7 years of program context into account, but ignores that costs in year 1 were lower than projected. There wasn't a massive withdrawal of pharmaceutical trials from the FDA or a massive unplanned ending of exclusivity periods coinciding with the start of Part D. The truth is that most of the exclusivity periods and new labels were on the radar forever.

The law was passed in 2003. It didn't go into affect until 2006.

Things changed in those years.

The fact of the matter is that the CBO did understand that the drugs on the marker would see their exclusitivity expire, but they assumed as part of their calculation that new drugs would also be developed and the same costs would be associated with them.

They assumed that the net effect would be that as a percentage of the market the generic use would stay about the same. That this historical trends would hold.

They actually weren't already holding when Part D was passed, they weren't holding when the CBO did their estimate, and they've continued to not hold.

Brand drugs have been rising faster than inflation for a very long time. Part D's drive to generics, coupled with similar benefit tiering now promulgating throughout health plans, has driven generic use up.

Generic use is up amongst the total population. There's no need to envoke a role of Part D in driving up generic use.

Lipitor is the biggest blockbuster drug ever. It's exclusivity period has been known forever. CBO can account for this stuff. If anything, Pfizer going the authorized generic route extended high prices for Lipitor longer than was previously predicted.

This is just false; willfully ignoring the scope of Part D. Yes, the cycle has plenty to do with this, but that cycle has been known. The FDA approval process, if anything, has gotten faster, not slower over these years. I'm not sure why it's so hard for people to admit that real marketplace dynamics among the population that uses the most drugs has also contributed to pricing. It's crazy to think it hasn't.

This just shows a lack of knowledge of the situation the Pharma industry is in and the how the estimates of the costs for Part D were done.

The CBO and others assumed that drugs going off of exclusitivity would be "replaced" by others that were not.

Everybody knew that Lipitor was going to go to generic, but the assumption was that the Pharma would create new drugs that other people would use at the same rate.

The assumption was that the percentage of the prescription drug market that was generics would resemble the historical norm and that the exclusitivity of the drugs being used would be essentially flat.

Neither of those two things have happened.

People discount because there is no evidence for it and there's no real reason it would happen, and we have plenty of data that pre-dates Part D that said it happened before Part D.

Before Part D, drugs came off their patent and generics were made that were cheaper. I don't need to invoke Part D for the same behavior that was happening before Part D to continue to happen.

Come on Peter, from wikipedia..."While the CBPP claims to be non-partisan, journalists have characterized it as liberal or left of center." Note that there are 8 citations for that quote.

Right, attack the souce not the actual information in it.

To hear detractors, they'd argue that this growth is purely a coincidence of timing that just happens to exactly coincide with a drug benefit that has tons of competitive mechanisms for a huge part of the highest drug users in the country. The least you can do is admit that people who are against the politics of the benefit have at least as much incentive to diminish Part D's achievements as its original supporters have to attribute all of its achievements to their ingenius benefit design. Politics goes both ways.

The difference between the two sides is that I see one side putting out real data from pretty reliabel source (e.g. the CBO and Health and Human Services), and I see the other side waving their hands around and saying don't look at this look a this other mumbo-jumbo

And again, generics coming onto the drug market that are cheaper than the non-generic after the exclusitivity period pre-dates Part D.

I don't need to invoke a Part-D related mechanism to explain that.

Squeeze the balloon. Medicaid can charge all the rebates it wants and all that does is raise WAC, which causes non-Medicaid drug programs to basically subsidize Medicaid. That's sort of good for Medicaid's bottom line, but not for drug costs in general. Force the same thing in Medicare and you'll just compound that effect. The difference between Medicaid rebates and Medicare rebates is pharmaceutical manufacturers are paying those rebates in Medicare because they need to pay them to get formulary access. If Medicaid wanted to have a positive global (in the US) effect on drug pricing they'd negotiate lower WAC/AMP pricing rather than bigger rebates. Manufacturer costs of rebating through Medicaid can be passed on to others.

Costs are related to supply and demand and not production costs. There is no "passing" on costs.

There is no current viable economic theory that includes the ability to pass on costs.

(I'll point out that I used to make a similar argument here w/ respect to our Pharma costs and countries like Canada, but as I've gained a better understanding of economic (mostly by reading this board), I've come to appreciate that argument is badly flawed.)

I literally created a table about this in 2007. Part D was ahead of Medicaid programs and outpaced projections for generic dispensing rates by just over 4%. I can't find it in my files...it was literally 6 years ago and I have changed jobs. In any case, if you wanted, you'd look for OIG reports about GDRs in Medicaid in 2005/2006 and compare to Part D and you'll find that Part D is ahead.

You know what I did. I looked at the link that I posted above (you know the one that you criticized for being biased) and then I found the reference in it.

https://oig.hhs.gov/oei/reports/oei-05-07-00130.pdf

"Department of Health and Human Services

OFFICE OF INSPECTOR GENERAL

GENERIC DRUG UTILIZATION IN THE MEDICARE PART D PROGRAM"

"For Part D, the overall generic drug substitution rate of 88 percent is similar to the median generic drug substitution rate of 89 percent for State Medicaid programs during 2004."

That is if people CAN use a generic they do so at an 88% for Part D. If they can in State Medicaid programs in 2004, they were at 89%.

(Please, note how they aren't just comparing the percentage of generics, but the subsititution rate. Comparing ONLY the percentage of generics is BADLY flawed because different populations will take different medicines that have differences in the availibility of generics (which is what the link you posted did).)

And:

"Overall, Part D achieved a high level of generic drug use during the first two quarters of calendar year 2006 that was similar to the level of generic drug use achieved by State Medicaid programs in 2004."

I think that should pretty much kill your argument.

The shift to generics when things go off patent pre-dates Part D. Over the life time and even pre-dating the creation of Part D, the people that did the estimates predicted things based on historical norms. Those historical norms were wrong right off the bat and have been for the life time of the program, but they weren't just wrong for Part D, they've been wrong for the whole US population and can be tied to decreases in exclustivity being granted by the FDA, which has been tied to decreased drug development by Pharma

That tied to lower than expected enrollment in Part D are the best and clearest explanations of the reduced costs of Part D.

We don't have to go to unsupported things like maybe Part D caused there to be more generics or lowered the prices of the generics.

There were lower priced generics before Part D. Companies made generics and people used them.

---------- Post added February-28th-2013 at 11:52 AM ----------

Well according to PeterMP it's a check box on a voting form.

Meanwhile back at the ranch.....

Yeah, that's what I've said.

---------- Post added February-28th-2013 at 12:23 PM ----------

The problem as I see it comes when the cure has been around forever, but it was a cure for something else. The incentive to go through trials to test the efficacy of a drug which has been out for 30 years treating another condition just don't seem to exist. Without the trials, the drug won't be used or covered.

I think we can do something about this in many cases by shifting the focus of the NIH. Right now, much of the focus of the NIH is about understanding diseases in a manner that allows for development of new drugs and even finding things that could be new drugs.

That is the NIH is funding the basic reserach that then underlies the Pharma industry.

We should shift much of the focus of the NIH to finding affects of things we already know or basic life style things.

We should be doing more large scale and long term studies on diet and even the use of prescription drugs.

If we can figure out how to treat Alzheimer's by life style or existing moleulces, does it really matter if we understand Alzheimer's disease in detail?

(though I think we need to continue to do pretty active drug development research on infectious diseases and the risks of new technology because those things change, but I don't think we do enough of that now anyway.)

[Special K]

Fat, unhealthy Americans?

TV, cars, lack of exercise, too much drinking, not walking enough, big macs, farm/ethanol subsidies and just a general laziness of our population

shall I go on?

Those are obvious problems, not really what I was getting at though.

More, does the problem primarily rest with pharmaceutical companies marketing directly to the American public? Lazy doctors? Lazy patients? All of the above? One more than the other? Etc.

Furthermore, how does one propose solving what they see is the problem?

Don't just tell me fat and lazy Americans. That's a very easy solution and more than obvious. How is that problem solved?

Just interested in people's thoughts on that.

[PeterMP]

Those are obvious problems, not really what I was getting at though.

More, does the problem primarily rest with pharmaceutical companies marketing directly to the American public? Lazy doctors? Lazy patients? All of the above? One more than the other? Etc.

Furthermore, how does one propose solving what they see is the problem?

Don't just tell me fat and lazy Americans. That's a very easy solution and more than obvious. How is that problem solved?

Just interested in people's thoughts on that.

More consistent and relevant information on what is good for you, including information that takes into account variation and variables (e.g. do the studies so that we understand at some real level how "over weigth" and at what age is really bad for most people and get out there consistently in a relevant manner.) than "positive" "information" for what is bad for you.

And this includes advertisements/commercials.

This is what worked for smoking (lack of ability of cigerette companies to advertise (e.g. no tv commercials) and anti-smoking advertising) and what hasn't worked in terms of obesity (e.g. people know that being overly obese, especially when you are young is bad, but numbers for childhood obesity keep going up because of the difference in advertisement of that information vs. the advertisements to eat (especially eat things that can contribute easily to being obese)).

[Larry]

This is what worked for smoking (lack of ability of cigerette companies to advertise (e.g. no tv commercials) and anti-smoking advertising) and what hasn't worked in terms of obesity (e.g. people know that being overly obese, especially when you are young is bad, but numbers for childhood obesity keep going up because of the difference in advertisement of that information vs. the advertisements to eat (especially eat things that can contribute easily to being obese)).

Think we should be running PSAs that are designed to make obese people look ugly, stupid, and evil?

(Yes, it's a sarcastic question.)

[Special K]

More consistent and relevant information on what is good for you, including information that takes into account variation and variables (e.g. do the studies so that we understand at some real level how "over weigth" and at what age is really bad for most people and get out there consistently in a relevant manner.) than "positive" "information" for what is bad for you.

And this includes advertisements/commercials.

This is what worked for smoking (lack of ability of cigerette companies to advertise (e.g. no tv commercials) and anti-smoking advertising) and what hasn't worked in terms of obesity (e.g. people know that being overly obese, especially when you are young is bad, but numbers for childhood obesity keep going up because of the difference in advertisement of that information vs. the advertisements to eat (especially eat things that can contribute easily to being obese)).

I would agree with this. I think there are a variety of tactics that need to be employed in the fight against America's epidemic of chronic disease and over-reliance on Rx's. Obviously, Rx's do a lot of good overall, but I agree that they are over-prescribed for a variety of reasons.

I think that restrictions need to be placed on pharmaceutical marketing, in magazines, newspapers, tv commercials and a million other media venues. The same restrictions placed on tobacco products should be placed on pharmaceutical drugs, IMO. Observations made during my time interfacing with patients in the medical setting absolutely makes me think restrictions on pharmaceutical advertising would go a long ways in helping reduce patient "need" for Rx's. I can't count how many times patients entered the clinical setting where I worked asking directly for Rx's they had read about online or seen on TV. The infiltration of these advertisements into our everyday lives is out of control and this type of marketing needs to be addressed by our legislators.

I would also agree with positive PSA commercials regarding healthy living, facts about obesity and chronic disease, etc. would be helpful.

I'm also in support of taxing "junk food" items similar to the way we tax tobacco products. I'm not sure what exact type of metric should be used to determine what constitutes "junk food" and falls under the tax umbrella, but I'm sure health experts could come up with an appropriate definition.

Finally, I think incentives for healthy behavior (weight loss, healthy eating choices, preventive care checkups, etc.) should be more widespread among the insurance, employer, public and private sectors. When I lived in Colorado, a health incentive program called LiveWell Colorado experienced success with its' incentive program for registrants engaging in healthy behavior activities.

Anyway, I'm sure there are many more ways to approach this probem, I'm just sick of hearing people say "we rely too much on prescriptions" and "we're fat and unhealthy" without really outwardly verbalizing their thoughts regarding the causes of these health issues and potential solutions for them. Clearly these diseases place an immense burden on our health care system and I agree with others who say expanding efforts in the preventive realm can very likely help some of the problems we are experiencing with our health care system.

[Corcaigh]

I would also agree with positive PSA commercials regarding healthy living, facts about obesity and chronic disease, etc. would be helpful.

Shown during cartoons. Encourage kids to pressure their parents about healthy lifestyle, unless they want to be destitute orphans.

[Wrong Direction]

Peter,
On my phone, so I'll try to be brief.

1. On GDR vs GSR, I remember the issue but can't recall the details. I will try to look it up tomorrow, mostly because I think the distinction doesn't actually favor Medicaid.

2. The law was passed in December 2003. Plans had to hire staff, negotiate pharmacy networks, negotiate rebates and formulary design. Write and submit bids to CMS in June of 2005. That's like 20 months, max, and plan bids all came in under projections. The pipeline didn't dry up in 20 months. Prices were lower because of competition.

[Larry]

I don't think I'd have a problem with even an outright ban on advertising prescription medication.

Maybe I wouldn't have a problem with something along the lines of "if you have <condition>, theres a new drug out that might help. See your doctor to see if its right for you". Not so much advertising, as letting the public know that there's a new option on the table.

But my reasoning is that, supposedly, the reason why a drug requires a prescription, is because its been determined that nobody but a doctor can decide if this drug is right for you.

And yeah, I remember when mom went through a phase where she'd call me into her room every time an ad for a drug came on tv, and tell me that she wanted it. (And she watched shows like Matlock. Where ALL of the commercials were for drugs, scooters you could get if you had Medicare, and lawyers wanting to sue drug companies).

[NoCalMike]

Are folks lazy to some extent? Sure. I wouldn't disagree, but I also think the population are being "poisoned" by some of the big food manufacturers.

It's also high questionable when you have board members hopping back and forth from the committees who regulate the food to the ones who regulate the medicine and back, then back again.

I think technology by nature has probably made us a less active society as far as "exercise" goes, but when I use the term exercise, I am not talking about taking an extra 2-3 hours out of the day to do it. I'd say 30-50 years ago, people were more active out of necessity, it wasn't necessarily because they were better or smarter about their health, it was because that is how it had to be done back then. As technology advances and more things become automated, it's just a matter of fact that many things that required an active lifestyle 50 years ago, don't anymore.

The problem is so complex.

[Special K]

Shown during cartoons. Encourage kids to pressure their parents about healthy lifestyle, unless they want to be destitute orphans.

Hellooooo, those would infringe on the airtime of junk food and toy commercials! I've been babysitting my 5y/o niece quite a bit and as a result, have been exposed to the crap commercials aired on Nickelodeon, Cartoon Network, etc. I can't count how many millions of junk food and toy items this kid has added to Auntie's "shopping list" as a result of these commercials So hey, if even a minimally positive outcome could come out of encouraging kids to place pressure on their parents to engage in fun, healthy activities with them or buy health food items that appeal to the kids, I'm all for it. I'm willing to look into anything at this point! I wish so much we had the money to mount these types of PSA campaigns and just inundate America with with healthy messages Like tobacco, maybe if we start taxing all this junk food, that revenue can be used in preventive efforts...

[gbear]

I see a lot of taxes proposed for things like sugary junk food and sodas. If we are going to go this route, and I don't think it's a bad idea, I would prefer a tax on salt content. If you go after salt content, you go after processed foods. If you take on that portion of our diets, I suspect the rest is taken care of as a by product.

On the incentive side, I know BCBS has offered a pedometer to my wife and I every year. Seeing how much you walk or run is encouraging. Incentives for maintaining or improving a body fat percentage could also help.

[PeterMP]

Peter,
On my phone, so I'll try to be brief.

1. On GDR vs GSR, I remember the issue but can't recall the details. I will try to look it up tomorrow, mostly because I think the distinction doesn't actually favor Medicaid.

2. The law was passed in December 2003. Plans had to hire staff, negotiate pharmacy networks, negotiate rebates and formulary design. Write and submit bids to CMS in June of 2005. That's like 20 months, max, and plan bids all came in under projections. The pipeline didn't dry up in 20 months. Prices were lower because of competition.

I've honestly only seen one other poster here that was so clueless on a topic insist that they really had any clue on the topic.

It is given in the link I've already posted:

"For Part D, the overall single-source drug-prescribing rate of 37 percent is similar to the median single-source drug-prescribing rate of 41 percent for State Medicaid programs during 2004."

And

"For Part D, the overall generic drug utilization rate of 56 percent is similar to the median generic drug utilization rate of 54 percent for State Medicaid programs during 2004."

The numbers are similar is what they concluded, but more importantly even if the numbers aren't similar its really irrelevant at the level of a prescription drug benefit.

It might suggest that there is something else in Medicare that is helping people not get diseases where they don't have the option of using a generic or possibly that Pharma is going out of there way to develope new drugs that are relevant to the Medicaid population more specifically (possibly not because they are on Medicaid, but because they are more likely to have characteristic X), or it might be a difference between the two populations that is simply inherent in them being different (e.g. environmental pollution issues related to differences in where they live based on their income.)

The most meaningful number is the substition rate, and they are very similar (1% a part) for the numbers we seem to have.

The initial CBO estimate was created in 2003 and so there are years in between where the estimate was done and people really started spending on drugs.

But it is even worse than that, in making its estimate the CBO didn't use 2003 data, they used older data for prescription drug use.

http://www.cbo.gov/sites/default/fil...4468/hr1s1.pdf

"The model contains detailed information about beneficiaries’ spending for prescription drugs and Medicare-covered services, their supplemental insurance coverage both public and private), their health status, and their income.2 CBO’s estimates of Medicare costs result from the operation of that model.3"

"The estimates are based on data from Medicare claims for 1999 and from the 2000 Medicare Current Beneficiary Survey,
projected forward using CBO’s March 2003 economic assumptions and baseline projections of Medicare spending.
3. For more general information about CBO’s prescription drug estimates, see Issues in Designing a Prescription Drug Benefit
for Medicare (CBO Study: October 2002).

8"

They used data from the height of the patent protection of the commonly used drugs (1999 and 2000) associated prices and inflation of costs to do their estimate.

Now, it was clear in 2003 when they did their estimate that there was PROBABLY going to be down turn (from 2000 there is a clear trend of a decrease in FDA granted exclusitivity, but at that point in time, it was only a 3 year trend, but at that point in time it was pretty clear that the large scale combinatorial chemistry approach for discovering drugs had failed so the pipeline was going to be down for a while), but they used the older data (probably because that's what they had in terms of real numbers (It has also seems to me that they more regularly over estimate costs/under estimate savings by using older data that it appeared wouldn't hold true they ensured they didn't underestimate costs)).

And then in 2005, the CBO actually up-dated their estimate, but in terms of drug prices and usage, they still went back and used the older data.

If in 2006, you would have used 1999/2000 data to estimate the drug costs of the US, even excluding Part D participants, you would have been wrong.

And there was "competition" before Part D. People were making generics. People were using generics. There were drug stores and insurance companies trying to cut as good as deals as possible to make more money for themselves or to recruit customers.

It isn't like there was no or even low prescription drug use prior to Part D.

You don't get to conclude because X was lower it was lower because of Y reason. How was the estimate done, what year did the data come from, etc?

What did they anticipate that the generic substitution rate would be and why?

When you do the estimate is irrelevant if you are using old data to do the estimate.

[China]

I see a lot of taxes proposed for things like sugary junk food and sodas. If we are going to go this route, and I don't think it's a bad idea, I would prefer a tax on salt content. If you go after salt content, you go after processed foods. If you take on that portion of our diets, I suspect the rest is taken care of as a by product.

Processed foods? How about artificially sweetened milk:

Artificial Sweeteners in Milk?

Got diet milk? In a highly controversial move, the dairy industry wants to market artificially sweetened milk—without any special label to alert consumers.

In a petition filed with the FDA, the International Dairy Foods Association (IDFA) and the National Milk Producers Federation (NMPF) seek to change the definition of “milk” so that chemical sweeteners like aspartame and sucralose can be used as optional ingredients not listed on the product label.

If the petition—originally filed in 2009 and now under consideration by the FDA—is successful, these hidden additives could also be included in 17 other dairy products—including whipping cream, low-fat and non-fat yogurt, eggnog, sweetened condensed milk, sour cream, and half-and-half—without requiring any special labeling.

The dairy industry contends that using artificial sweeteners like aspartame as optional ingredients in milk and other dairy foods without any special labeling would “promote more healthy eating” and boost kid appeal. Currently, milk consumption is dropping among both children and adults.

Click on the link for the full article