VentureBeat

Patients, patients everywhere, yet not a doc to treat – From Massachusetts to Colorado, there’s an increasingly acute shortage of primary-care physicians. In Massachusetts, where the nation’s only universal healthcare plan is gearing up, hundreds of thousands of newly insured individuals are having trouble finding doctors. According to this report, new patients wait an average of 52 days to see an internist or family doctor for a routine visit, and with up to 500,000 people set to get insurance this year, the head of the Massachusetts Medical Society is predicting a crisis of healthcare access. There’s more here and here, just for starters. Google “Massachusetts doctor shortage” for much more.

Things aren’t much better elsewhere across the country. In Colorado, a new report finds that close to a third of the state’s primary-care docs are 55 and over, and that relatively few younger docs are entering the field to replace them. (See the PDF report itself here.) Meanwhile, those on the lowest rungs of the economic ladder are also finding it increasingly difficult to get treatment because so many doctors have either stopped accepting Medicaid patients or severely limited their numbers. The WSJ Health Blog has more, including another post about two Illinois clinics sued by the state for allegedly colluding to stop seeing new Medicaid patients.

The reason for the doctor shortage is actually pretty simple: Salaries are much, much higher in specialties such as surgery and radiology than they are for your workaday general practitioner — sometimes by a factor of two or more, the NYT reports — and the workload is often less. Primary-care physicians also perform fewer complex medical procedures, which limits the reimbursement they can seek from insurers or Medicare.

The rest is pretty much just supply and demand — and a useful reminder that real fixes for the nation’s busted healthcare system are going to demand some fairly dramatic changes. Some radicals like Alan Garber, a Stanford healthcare expert quoted in the NYT, would like to see doctors paid fixed salaries and bonuses based on how healthy they keep their patients, which would level the playing field among physician specialties and create incentives to treat and prevent illness instead of just treating it with the most expensive procedures available. Just imagine how excited the American Medical Association would be about that.

States can’t do healthcare reform alone – While we’re on the subject, this piece by Ezra Klein in the Washington Monthly makes a compelling argument that states can’t provide universal healthcare on their own. It’s a complex argument, but much of it boils down to the fact that states typically can’t sustain the heavier healthcare costs brought on when recessions throw more people out of work and the health insurance they get from employers. Klein notes the “cruel irony” that state healthcare spending typically gets cut during downturns, just when people tend to need government help the most. Only the federal government, he suggests, has the resources to maintain and even expand healthcare programs when times get tough. (For the internecine warfare that broke out among liberal progressive bloggers shortly after Klein’s article was published, see here, particularly the comments.)

First thing, we kill all the ad salesmen – Although free-market types like to talk about drug advertising as providing a “useful source of information” to consumers, the reality is a lot more complex. Advertising essentially creates demand for many drugs, leading patients to visit their doctors waving magazine ads or asking about “the little purple pill” (a fantastically effective campaign earlier this decade for the heartburn drug Nexium). Needless to say, very little of this has anything to do with keeping people healthy, and quite a lot to do with boosting drug sales.

Over at BrandweekNRX, Jim Edwards pens a farewell post offering 10 drug-advertising reforms that would do a lot to make pharmaceutical-marketing programs more informational and less manipulative. With Congress having apparently passed on letting the FDA regulate drug ads more thoroughly, though, the odds of any of these idea passing into law seems remote at best.

Additional oddball note: Jim’s replacement at BrandweekNRX is none other than Peter Rost, former Pfizer marketing exec-turned-scathing critic of the industry that once paid him. Rost has an odd sense of humor and can certainly carry on at times, but he’s entertaining, muckraking, and always worth a read.

Hospitals as charity cases? – One of the tradeoffs involved in running a hospital as a nonprofit entity, a status that grants some pretty hefty tax breaks, involves providing charity care to the indigent. It turns out, though, that many hospitals are pleading poverty themselves. A recent IRS report, noted in the WSJ Health Blog, found that nearly a quarter of nonprofit hospitals spent less than one percent of their revenue on care for the disadvantaged, while half spent less than three percent. Now moves are afoot in Congress to require nonprofit hospitals to devote at least five percent of revenue to charity care. For more, follow the link.

Briefly noted:

• Congress is struggling to increase funding for a federal program that insures poorer kids, against a veto threat from President Bush. The NYT and the WSJ Health Blog have more.
• A severely brain-damaged man regained his speech after treatment with pulses of electric current, the NYT reports.
• Medicare relaxed proposed guidelines that would limit the use of anemia drugs like Amgen’s Aranesp in cancer patients, after safety problems emerged; Amgen promptly challenged the watered-down guidelines.
• Researchers reported finding a genetic link to multiple sclerosis; surprisingly, there’s also one for “restless legs syndrome,” which some cynics considered a pharmaceutical-company invention.
• Older docs square off with their younger colleagues — and academics, patients, and others — over whether it’s a good idea to limit the work hours of notoriously sleep-deprived residents in comments at the WSJ Health Blog.

Arm wrestling over drug patents – Three months ago, the military government running Thailand informed Abbott Laboratories that it intended to break the company’s patents on several expensive drugs, including the HIV protease inhibitor Kaletra, thus allowing the manufacture or import of cheaper knockoffs. Abbott responded by dropping its plans to bring newer drugs, including a heat-resistant version of Kaletra, to Thailand, and the pharma and the junta have been locked in a standoff ever since. Over the weekend, Abbott offered to make the new version of Kaletra available at a deep discount price if Thailand left its patents alone; so far the government hasn’t responded.

The issue is a serious one for drug companies, including the handful of biotechs — among them, Gilead Sciences and Vertex Pharmaceuticals — who make or hope to launch drugs against developing-world scourges such as HIV and hepatitis. Years of high-handed behavior on the part of Big Pharma have fueled a militant backlash in poorer nations against the makers of high-priced, life-saving drugs. The Wall Street Journal has an in-depth look at the issue today. Here’s an excerpt:

Global drug makers are increasingly looking to emerging markets to compensate for slowing growth in the U.S., Europe and Japan. Abbott’s troubles in Thailand suggest that cracking the new markets can be tough because governments are driving a hard bargain on price. They are using the threat of breaking patents to get good deals. Thailand has won the support of nonprofit groups and world organizations while meeting little resistance from the U.S. government….

A number of emerging nations are working on plans to slash drug costs. Lawmakers in the Philippines are debating legislation that would permit breaking patents in certain circumstances and allow the country to use more generic drugs to fight AIDS and potential pandemics. Kenya is considering breaking patents as Dr. Mongkol has done to open the door to cheaper copies.

In an interview last week, Indonesia’s U.S.-educated trade minister, Mari Elka Pangestu, said her country might introduce price caps to bring the price of branded drugs closer to the level of generic equivalents. “The difference in price between nongenerics and generics is perceived to be too high,” Ms. Pangestu said.

Such moves could threaten the ambitions of drug companies in developing nations — especially those such as Thailand that are growing wealthier. While the U.S., Europe and Japan account for the vast majority of sales at big Western drug makers, their growth is slowing. The U.S. this year will contribute about 36% of total growth in pharmaceutical sales, down from 54% five years ago, according to a forecast by IMS Health, a research and consulting firm.

Heart problems in the elementary-school set – Another WSJ story chronicles a previously overlooked angle to the obesity debate: Kids as young as ten are turning up with early signs of heart disease. The finding emerged by accident when researchers enrolled 50 seemingly healthy kids in a clinical trial, only to find via echocardiogram that several had enlarged hearts — a condition known as left ventricular hypertrophy. LVH is typically associated with a high body mass index, but doctors apparently hadn’t even noticed that these kids were overweight, quite possibly because they see so many heavy children that their mental picture of “average” was skewed.

Fear and loathing among biomedical researchers – Earlier this decade, a sustained push to boost biomedical research doubled the NIH budget in five years. Now, however, the unintended consequences of that rapid increase are coming home to roost. This news story in Science lays out the basic problem: Big budgets attracted more scientists and led universities to build bigger and larger labs, but now that demand for research money is higher, budgets are flat, leaving less to go around. For a personal take on the situation, check out this post from “Orac,” a pseudonymous surgeon/scientist at Respectful Insolence.

Google your health records? – Biotech/pharma consultant David Williams, blogging from the World Health Care Conference in Washington, reports on a speech by Google’s Adam Bosworth and thinks a Google healthcare initiative might not be that far off. (A quick glossary for anyone clicking through to Williams’ acronym-heavy post: EHR stands for “electronic health record,” while PHR means “personal health record” — the distinction, apparently, being that an EHR is maintained by a health-care provider, while a PHR is owned and updated by the patient. If you want to know more, try this explanation. PBM, meanwhile, stands for “pharmacy benefit manager” — it’s essentially a catch-all phrase for pharmacy chains and other companies that manage the business of buying drugs and filling prescriptions. Aren’t you sorry you asked?)

EHR SNAFU – Yet another WSJ story today outlines the technical problems Kaiser Permanente has experienced as it tried to roll out an electronic-records system — while, of course, squelching a whistleblower who sought to draw attention to the issue. Merrill Goozner, who’s also at the World Health Care Forum, has more on the subject of electronic records and how they might — and might not — encourage competition among doctors here and here.

AstraZeneca chief acknowledges drug-promotion issue – According to this article in The Independent, AstraZeneca CEO David Brennan has acknowledged the possibility that his sales reps may have been improperly promoting the company’s chemotherapy drug Arimidex, and suggests that the issue is under internal investigation. (Hat tip: Peter Rost.)

Two fascinating papers in the open-access journal PLoS Medicine turn a spotlight on the practice of “detailing” — the office visits that drug-industry salespeople use to flatter and manipulate their way into the good graces of the doctors they want to influence.

The first and most eye-opening paper is co-authored by Shahram Ahari, a former Eli Lilly sales rep, and Adriane Fugh-Berman, a Georgetown University professor who researches drug marketing. Together, the two outline a variety of tactics that sales reps use on detail visits to disarm doctors and to indirectly — sometimes all but imperceptibly — nudge them into prescribing their company’s drugs more freely. This is one of those papers that best speaks for itself, so I’ve excerpted some key passages below. For the full effect, though, read the whole paper; Table 1 alone is worth the price of admission.

Good details are dynamic; the best reps tailor their messages constantly according to their client’s reaction. A friendly physician makes the rep’s job easy, because the rep can use the “friendship” to request favors, in the form of prescriptions. Physicians who view the relationship as a straightforward goods-for-prescriptions exchange are dealt with in a businesslike manner. Skeptical doctors who favor evidence over charm are approached respectfully, supplied with reprints from the medical literature, and wooed as teachers. Physicians who refuse to see reps are detailed by proxy; their staff is dined and flattered in hopes that they will act as emissaries for a rep’s messages. (See Table 1 for specific tactics used to manipulate physicians.) [...]

The purpose of supplying drug samples is to gain entry into doctors’ offices, and to habituate physicians to prescribing targeted drugs. Physicians appreciate samples, which can be used to start therapy immediately, test tolerance to a new drug, or reduce the total cost of a prescription. Even physicians who refuse to see drug reps usually want samples (these docs are denigrated as “samplegrabbers”). Patients like samples too; it’s nice to get a little present from the doctor. Samples also double as unacknowledged gifts to physicians and their staff. The convenience of an in-house pharmacy increases loyalty to both the reps and the drugs they represent….

Pharmaceutical companies spend billions of dollars annually to ensure that physicians most susceptible to marketing prescribe the most expensive, most promoted drugs to the most people possible. The foundation of this influence is a sales force of 100,000 drug reps that
provides rationed doses of samples, gifts, services, and flattery to a subset of physicians. If detailing were an educational service, it would be provided to all physicians, not just those who affect market share…. Physicians are susceptible to corporate influence because they are overworked, overwhelmed with information and paperwork, and feel underappreciated. Cheerful and charming, bearing food and gifts, drug reps provide respite and sympathy; they appreciate how hard doctor’s lives are, and seem only to want to ease their burdens.

The second paper isn’t anywhere near so colorful, but compensates with depth of analysis. A research team at the University of California, San Francisco, studied market-research forms for the anti-seizure drug Neurontin (generically known as gabapentin), which became public as the result of a whistleblower lawsuit against Neurontin’s maker, Pfizer. That lawsuit contended that the former Parke-Davis — later acquired by Pfizer — had violated federal rules by promoting Neurontin outside its FDA-approved uses, and concluded with a $430 million out-of-court settlement.

By studying 116 of the market-research forms filled out by selected doctors following a sales rep visit — here’s an example:

– the researchers built a detailed picture of the way Neurontin detailing worked. In 44 percent of the visits, physicians reported at least one “off-label” message related to Neurontin use in an unapproved fashion — exactly the sort of thing sales reps are forbidden to introduce in such conversations. Almost a full quarter of the visits involved only discussion of unapproved uses of the drug. (The researchers acknowledge that they have no way to know if the sales reps initiated such conversations.) Ultimately, almost half of the doctors involved said they planned to increase their prescription of the drug following the visits, while none reported plans to decrease Neurontin use.

Interestingly enough, former Pfizer exec Peter Rost is now closely tracking what may be a similar scandal related to AstraZeneca’s promotion of its chemotherapy drug Arimidex. The story, which began with the firing of an AstraZeneca regional sales manager who compared doctors’ offices to “a big bucket of money” in an internal newsletter, then mushoomed to include a cabal of alleged whisteblowers and leaked audio recordings — supposedly of AstraZeneca sales-rep training sessions — is detailed at his sometimes quirky blog Question Authority. If you don’t mind working backward, start here and keep scrolling down. Way, way down if you want to get all the way to the beginning — Rost is nothing if not prolific.