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Dr. Jack Kevorkian


Lowell Schnipper, the chairman of the ASCO Value Framework Task Force was also part of a group that supported Dr. Jack Kevorkian and pushed to legalize physician-assisted suicide.

It raises the question: Does the Value Framework recycle the arguments and assertions Dr. Schnipper made in pushing euthanasia as an option for cancer patients in determining how to value drugs and why?

To my mind, it does. 

Schnipper, who is also Chief of Hematology/Oncology at Beth Israel Deaconess Medical Center in Boston, has been a driving force in making ASCO focus on the costs and value of cancer care.  His support of Kevorkian and assisted suicide legislation are relevant. Specifically, just as Schnipper believed that hastening death when further treatment could only add a few months of life was legitimate, the Task Force he leads asserts that a few months or weeks of life have no clinical value and that further treatment is a waste of money at that point. 


Background

In 1998 Schnipper was part of “a high-powered collection of area doctors, academics and lawyers has been meeting privately, working to draft a model bill allowing physician-assisted suicide. "We'd like to get this bill introduced in Massachusetts and elsewhere," says Boston College law professor Charles H. Baron.
The group includes James Vorenberg, former dean of Harvard Law School; Judy Johnson, associate general counsel at the New England Medical Center; Dr. Lowell Schnipper, chief of oncology at Beth Israel Hospital; and Dr. Sydney Wanzer of the Harvard Law School health services. Most of the 10 members, says Baron, support legalization "in the hopes that this will make relief from suffering more readily available and in a less discriminatory fashion and with greater patient autonomy."

Schnipper’s Working Group Supported Dr. Jack Kevorkian

Dr. Wanzer noted: "If Dr. Kevorkian does it a little outside the niceties of proper practice, I can't condemn him for that. If I do this privately and quietly and discreetly, it doesn't force the issue. But he does. I think it's a good combination of the quiet people who go ahead and do what they think is right and the Dr. Kevorkians who do it more flamboyantly."

"Kevorkian is a result of failures of our medical system in caring for someone with intractable or chronic problems," says Dr. Lowell Schnipper, chief of cancer treatment at Boston's Beth Israel Deaconess Medical Center. "But Kevorkian is becoming more and more marginalized as legitimate groups begin to weigh in with the resources and sensitivities the problem demands, which to me is good news."

Schnipper also described hastening death as "consistent with the highest goals of the physician as healer and must be an option in a pluralistic society."

Today Schnipper Believes Cancer Treatment That Adds ‘Only’ Three Months of Life is Not Worth It.

In 2010 Schnipper was the lead author of an article that argued:

“Patients' high expectations of cancer therapy may be another cost driver
In a culture that favors treatment and has an overly optimistic view of what medicine can offer, it is an uphill battle for cost-conscious oncologists to communicate the true value of various forms of therapies, particularly when curative treatment options are lacking.”

He also notes:

“This problem may be particularly American one; other cultures do not seem to view the postponement of death by a few months as holding an equivalent importance. Culturally, are we entirely honest in our assessment of what a few months, particularly spent in illness, can accomplish?”


Value Framework Also Embraces Notion That A Few Months More Of Life Is Not Worth It

Schnipper, writing for the Task Force concludes:

“Cancer drug spending is being driven by “sometimes unrealistic patient and family expectations that lead clinicians to offer or recommend some of these services, despite the lack of supporting evidence of utility or benefit.”

Patients “ also overestimate the benefits of treatments that sometimes extend life by only weeks or months or not at all. 


Schnipper Established A Cut Off Point For Value Measured By a 20 percent increase (3 months) in yearly survival

Over the past two decades Schnipper has advanced an economic argument for cutting off cancer treatments.  Initially, he maintained that survival time should be increased beyond a specified amount of time:

“On average they (cancer treatments) may delay death for only a very short time, for example 3 months. Although some patients may live for more than 3 months, others will not necessarily live even that long. The drug only slows the progression of the patient's cancer by a few months; it does not “cure” the cancer. The psychological force of the rule of rescue should be much weaker in the context of this cancer care than in mine collapses. It should not make it impossible to resist providing the treatment, and certainly does not justify doing so. “  (In this regard, applying Schnipper's logic to everyone means stopping treatment for  every patient that does not gain more than 3 months on average, including babies, HIV patients and children with rare diseases. ) 

The Task Force Cutoff for Value Is The Same As Schnipper’s

Under his leadership of the Value Task Force, the 3 month cut off was turned in to a specific increase in survival as a percentage of a year of life: “It was generally agreed that relative improvements in median overall survival of at least 20% are necessary to define a clinically meaningful improvement in outcome. “    On average, 20 percent ranges from weeks to a few months.   This is a value judgment that applies to all patients with all forms of cancers with all different tumor types.


Schnipper believes that below a certain increase in survival money spent on dying cancer patients should be spent elsewhere to ensure resources are distribution ‘fairly.’

He claims: “The result of abandoning reasonable value standards in the face of urgency would be the use of much very high-cost, marginal-benefit care for dying patients. This situation is arguably our current practice in much care, including cancer care, of dying patients. But it is neither a rational nor ethical use of limited resources. The money spent on this very expensive, but marginal benefit, end-of-life care, could produce greater benefits if spent elsewhere either within or outside the health care system.

Schnipper goes on to state a cut off level:

“A cancer treatment that postpones death on average for 3 months at a cost of $100,000 does not produce…a large benefit.   The opportunity costs of securing that treatment are much too great.”

Schnipper has argued that spending on overage increase of three months comes at the expense of other uses of money. 

“A life-saving treatment like an appendectomy generally produces a very large benefit; it prevents the patient's death and returns him or her to a healthy life. But a cancer treatment that postpones death on average for 3 months at a cost of $100,000 does not produce such a large benefit. The life extension is short, and the quality of life during it is often poor. It is not a large enough benefit to trump the greater benefits to many that would have to be foregone to provide it.”


Similarly, the Value Framework declares:

“Oncologists should be aware of the value of an intervention in terms of societal cost. Clearly, increasing health care costs are eventually transferred to the consumers of health care, if not in the form of out-of-pocket costs, then in the form of higher insurance premiums, higher taxes, or limited wage increases as employers confront the escalating costs of providing health care to their employees."


What Schnipper and The Task Force Ignore

The task force asserts that spending on new cancer drugs bankrupts individuals and our healthcare system.  But the benefits to patients are palpable.  Drugs that emancipate our immune system to attack tumors or target specific genetic cancer causing mutations have transformed cancer care.  These cancer drugs are expensive no doubt.  Yet they account for only account for 0.7 percent of the $2.9 trillion we spend on health care.   Cancer spending has increased in 1995 from $42 billion to about $130 billion today.  But its share of total health spending declined from 4.7 percent to 4.4 percent during the same time period. 

New medicines reduce the cost incurred by a cancer diagnosis, for instance in part by reducing hospitalization.  In 1996 drugs were 3.7 percent of cancer spending and 62.4 percent went to hospitalization. By 2012, drug spending was 9.3 percent of cancer costs while the share going to hospital stays dropped to 41.3 percent.    If we were allocating the same proportion of money to hospitals today, as we were in 1996, we’d be spending about $18 billion more a year on cancer.  And we have yet to see the full benefit of the cancer drugs not yet included in these estimates. 

As the price and number of new treatments increases, their value increases too. A recent Bureau of Economic Analysis study found between 2000-2010 that “medical technology (for treating cancer and other costly illnesses) is improving over time, leading to better health outcomes at a lower cost per patient.”   A lot of that has to do with medicines displacing less effective and more costly oncology services.  Why does the ASCO Value Task Force ignore that. 


Conclusion

Between the time Schnipper was pushing for assisted suicide until the time that he has begun pushing to limit the use of cancer drugs for people with “only” three months to live cancer survivorship has surged from 10 million to 14 million people and life span expressed by 36 million life years worth about $3 trillion.

If Schnipper’s vision had become common practice how many of those survivors would not be alive today?  How many will not live because of his current plans? 





The announcement that Aprecia Pharmaceuticals has produced the first 3-D printed drug approved by the Food and Drug Administration  prompted a slew of articles about the technology that produced it.   There as no coverage about what it took to move 3-D printing from being a science fair project to a tool for mass production of customized medicines. Nor has their been any discussion about the implications of such commercialization on medicine. In particular,  the marketing of 3-D printed drugs underscores Sir Harold Evans observation that “innovation is not simply invention; it is inventiveness put to use. Invention without innovation is a pastime.”

















The emphasis  on ‘pragmatic’ is what distinguishes invention from innovation.  Michael Shrage,  a research fellow at MIT Sloan School's Center for Digital Business says that innovation is not what innovators do but what customers adopt.    Semi-conductors were an amazing invention but no one really saw any use for them beyond industrial applications:  then someone came up with idea of using one programmable chip to make personal electronic calculators.   It wasn’t long after that the PC revolution was launched.  

While Human Genome Project was a worthwhile investment, it was only made so by the efforts and investment undertaken to make it’s tools accessible and to product medicines and devices that millions could use.  Otherwise it would have been a very expensive science fair experiment as well.

The sale of 3-D printed medicines demonstrates that it is possible to make targeted medicines or treatment combinations widely and quickly available.   Often overlooked in the discussion about Aprecia is the fact that it applied it's manufacturing process to medicines that are in short supply because generic companies have found them too expensive to make using existing technologies or because they are products -- such as those for neurological conditions -- require absorption and availability within very narrow therapeutic indexes.   Finally,  the Aprecia approval is notable because it takes an injectable drug and turned it into a pill (Spritam).   Levetiracetam is used to control pediatric (and adult) epileptic seizures.   A stable, oral medication that works more quickly and can be produced in real time meets an important clinical need and solves a growing problem of drug shortages.  Can we say disruptive? 

Finally,  it should be noted that Tom Arrington, who invested in Aprecia many years ago, placed a huge bet on 3-D printing of drugs.  He didn't need the money.  In fact, Mr. Arrington has a successful authorized generic company Prasco Laboratories. .  Like many other entrepreneurs, Arrington's goal was not making more money. There a less risky ways to make a return.  Rather, profit is a means to an end that other incentives cannot easily achieve.  As Sir Harold noted: "Iinnovators are committed to making their developments as widely available to the populace as possible. This mass market democratization has been a hallmark of American success in the world."

Commercialization is part of the virtuous cycle that has made progress against disease and in enriching and extending life possible.  Aprecia has opened the door to the commercialization of medicines that can serve unique populations and it creates unprecendented opportunity to repurpose injectable medicines so that they are easier to administer, ship and store.  But the effect of commercialization cannot be divorced from the character of the person making it possible.

The Talmud observes:  Which is the best path for someone to choose for themselves?  Whatever is harmonious for the one who does it, and harmonious for mankind.

That sums up the path Tom Arrington took when he invested a small fortune in Aprecia. 
Frances Kelsey,  a medical officer with the Food and Drug Administration in the 1960s died last week at the age of 101.  She has been celebrated as the FDA official who kept thalidomide from being marketed in the United States.  

Thalidomide was never approved in the US.  In fact, as noted in Regulating New Drugs: The application was delayed for reasons having nothing to do with potential risks and was moving towards approval when the company itself reported the horrible side effects.  It took four months for the FDA to realize that people were at risk and in fact Helen Taussig, a cardiologist at Johns Hopkins University had been sounding the alarm about thalidomide for years.  The FDA finally acted after John F. Kennedy insisted on it.  

The current FDA approach -- a product of the 1962 amendments to the Food and Drug Cosmetic Act -- and dependency on the randomized controlled trial is a legacy of the political reaction to a problem.  Efforts to increase regulatory flexibility at the FDA are opposed, the critics always invoke "another thalidomide." 

Most people stop the story there. It’s an open and shut case, they say, thalidomide was a horribly dangerous and deforming drug allowed to get onto and stay on the market due to grossly inadequate safety testing and monitoring and the callous actions of companies interested in profits over patients. This, they believe, is why we cannot be too careful about any drug that might be risky. But the tale of thalidomide doesn’t end with its withdrawal – and millions have lived better, longer lives because of it.

In the mid-1960s, thalidomide came back to life. As many discoveries in medicine are, it was due to chance. Dr. Jacob Sheskin was the head of the Jerusalem Hospital for Hansen’s Disease (or what most people call leprosy) when one day he was sent a patient with extremely advanced erythema nodosum leprosum or ENL, a very painful and debilitating side effect of leprosy that causes boils, joint pain, inflammation, and intense pain. Patients waste away, unable to eat or sleep and dependent on morphine and sedatives to control their agony. About 60 percent of people with advanced leprosy get ENL.
The patient who arrived at the Jerusalem Hospital in 1964 was close to death and had received almost no benefit from any sedative available. While trying to figure out whether there was anything that could be done for him, Dr. Sheskin stumbled upon a small stash of thalidomide, now no longer sold. But remembering the use of the drug in mental patients who similarly responded to no other sedative, the doctor decided it was worth a try. It worked. Spectacularly. Not only was the patient finally able to sleep but his ENL began to improve radically. The same thing happened with other patients with ENL. Sheskin then embarked on a series of controlled clinical trials in Venezuela, where thalidomide could still be purchased, and confirmed his findings. Soon the drug was promoted by the World Health Organizations for use in ENL patients and because of it the vast majority of facilities to treat leprosy have been able to be closed. Even the US allowed highly controlled use of thalidomide for ENL beginning in 1975.

In the 1980s, thalidomide found another use: AIDS patients. Like those with ENL (and tuberculosis patients, who had also been helped by thalidomide), people with AIDS suffered from severe wasting. They also got sores in the mouth and esophagus called aphthous ulcers, caused like the wasting by caused by a chemical called TNF-ɑ (tumor necrosis factor alpha), and a rare cancer called Karposi’s sarcoma. The drug worked well, but it was hard to get a hold of. Many AIDS patients obtained it from abroad, mostly via Mexico, through buyers’ clubs but these channels were dubious and the quality and purity unsure. Researchers into the uses of thalidomide had likewise found that it was difficult to obtain and so one, Dr. Gilla Kaplan, finally managed to convince a small pharmaceutical firm called Celgene to apply to the FDA for approval to produce thalidomide.

While the process to get the drug through the FDA was ongoing, research into its potential use as an anti-cancer drug was in process by leading cancer researchers Dr. Robert D’Amato and Dr. Judah Folkman. They were working on angiogenesis, the growth of blood vessels, and hoped that finding a way to inhibit it would allow the development of drugs to fight cancer, as well as several other diseases. It was thalidomide’s anti-angiogenic effects that caused the birth defects but also made it a perfect candidate from D’Amato and Folkman’s research. Subsequent study found that the drug is also very effective against multiple myeloma, a difficult to treat cancer that attacks the plasma cells in the blood.  In July 1998, after a long and spirited debate and heartfelt stories from both victims of thalidomide and those helped by it, the Celgene drug --Thalimid was approved by the FDA under the condition that patients are carefully monitored and extensive safeguards enacted to prevent pregnant women from taking thalidomide.  Once in use, the benefits of thalidomide analogues in resetting the immune system to reduce tumor growth, became apparent.  It launched a whole new field of treatments and the introduction of several new medicines.  New uses, especially for rare autoimmune conditions, are still being discovered, even as old ones are sometimes superceded. In its current usages, the drug has benefited millions of patients around the world.

The thalidomide story is a many told tale:  Each year millions of people suffer because fearmongers invoke the handful of side effects or deaths from the use of a medicine.  Indeed, the number of adverse events from drugs as a percentage of all prescriptions did not change after the 1962 amendments.  The number of withdrawals as a percentage of all medicines has remained the same.   FDA regulation is a very expensive tranquilizer to calm the nerves of the public.  We have more expensive medicines, fewer new medicines for specific groups of patients and less competition.   

Enshrining Francis Kelsey as a hero is a ritual detached from the truth.  It is an exercise designed to reinforce the precautionary approach that has slowed down the development and use of medical innovations for over 50 years.  

Essuring safe use

  • 08.10.2015

Do women deserve choice when it comes to contraception? On September 24th, the FDA will hold a meeting of the Obstetrics and Gynecology Devices Panel of the Medical Devices Advisory Committee to discuss the risks and benefits of Bayer HealthCare’s Essure System for permanent female sterilization. It’ll make for some strange bedfellows.

Essure is a small metal and polyester coil placed into a woman’s fallopian tubes in order to make her permanently sterile. FDA approved Essure after a fast-track review process that prioritized the device because it offered the first alternative to surgical sterilization and promised a quick recovery.

The big picture was lucidly presented by Essure manufacturer, Bayer, in a letter to the New York Times, “Women deserve access to a wide range of contraceptive options, and Essure is an important non-surgical and non-hormonal option for women who have completed their families and want permanent birth control. However, no medical device, procedure, or even drug is completely free of side effects.”

According to Dr. Bill Maisel, deputy director for science and chief scientist at the FDA’s Center for Devices and Radiological Health. “The agency believes the benefits outweigh the risks in appropriately selected patients who are adequately informed.” The FDA adcomm will examine and discuss an extended (5-year) follow up of a phase III trial evaluating the effectiveness, safety, tolerability, and satisfaction of hysteroscopically placed Essure inserts. Hopefully it will also discuss ways to better educate both patients and physicians about which methods of birth control are most appropriate given a woman’s specific situation and medical history.

The FDA’s job is to weigh the risks and benefits of the products it reviews and regulates. Most people only hear about these issues as they relate to pharmaceuticals – but the regulation of medical devices deserve far more attention then they currently receive from the media, physicians, and patients.

At the FDA, there is a program called the “Safe Use of Drugs Initiative.” The theory is that the way you make drugs safer is to ensure they are used as directed. The Safe Use strategy calls for better and more regular education for both healthcare providers and patients. And it works. It strengthens the sinews of safety. Knowledge is Power.

The Affordable Care Act provides universal coverage for female contraception. As more patients avail themselves of the many FDA-approved options, shouldn’t we also be designing strategies and tools to ensure safe use for birth control via medical devices? That should certainly be a key discussion point at the upcoming FDA hearing. But even more urgently, shouldn’t the agency design and implement a more comprehensive Safe Use of Medical Devices program?

Essure is a good example of the broader opportunity. According to Diana Zuckerman and Laurén Abla Doamekpor of the National Center for Health Research, two of the biggest issues with Essure is (1) physicians improperly insert the product and (2) patients do not return for their mandatory hysterosalpingogram. A solid and strategic safe use program could directly address both of these problems. The way to make a medical device “safer” is to ensure that it us used as directed. Not rocket science. Will the National Center for Health Research and women’s health advocates stand up at the FDA adcomm and call for better patient education? Hope springs eternal.

The Essure advisory committee will certainly delve into the details of the data – and that’s their main job – but it’s also a timely and important opportunity for those offering open public comment to call on the agency to develop a Safe Use of Medical Devices initiative. Patients using Essure will benefit – as will the hundreds of millions of Americans (men and woman, children and adults) whose lives are improved through the use of medical devices and technology.

Caronia Rules

  • 08.07.2015

Amarin has won their request for injunction against the FDA. Caronia lives!

The preliminary injunction granted. The court agreed Amarin materials are truthful and took the government to task for essentially arguing that speech alone can be the basis for liability and that the agency’s action is at odds with the Caronia holding and the First Amendment

More to come.

The ASCO Value Task Force attacks the very patient preferences it has pledged to respect and integrate into it’s tool by claiming that the ‘crisis’ of cancer drug spending is being driven by “sometimes unrealistic patient and family expectations that lead clinicians to offer or recommend some of these services, despite the lack of supporting evidence of utility or benefit.”

If it hasn’t made its view clear by now, the Task Force also asserts cancer patients “ also overestimate the benefits of treatments that sometimes extend life by only weeks or months or not at all. “ Oncologists are generally aware of this conundrum but uncertain about whether and how the cost of care should affect their recommendations. Although raising awareness of costs and providing tools to assess value may help to manage costs while maintaining high-quality care, some oncologists see this as being in conflict with their duty to individual patients.”

This amounts to a tacit effort to encourage assisted suicide, a cause Task Force chair Lowell Schnipper has promoted for 20 years. 

Here's the best response to this cold calculus 

https://www.youtube.com/watch?v=8Fo2uNqKMR8




Take any article on the cost of hepatitis C drugs -- doesn't matter -- they are all numbingly the same and one dimensional and replace sovaldi with ebola vaccines and hep c with ebola.   Then see if $84K for a cure  -- the possibility of which was widely reported and retweeted  -- is worth it.   

I chose a most recent article by Michael Hiltzik of the LA Times for this exercise.. Here's a link to the original un-original article about Sovaldi and here it is with the disease and cures swapped out....


How a hugely overpriced Ebola Vaccine helped drive up U.S. health spending

There's one especially eye-catching number in a new report by Medicare actuaries about U.S. healthcare spending: 12.6%. That's the leap in prescription drug spending last year over the year before. How sharp an increase is it? It was five times as much as the increase for 2013 over 2012, which was a mere 2.5%. The actuaries have no doubt what's driving the increase. It's "a result of expensive new treatments for ebola ," they write in their report for the journal Health Affairs.

And more than any other drugs, that means the Ebola vaccine, which cost about $84,000 for a 12-week treatment, or about $1,000 per once-a-day pill.

The increase in prescription costs was a sizable contributor to an increase in U.S. healthcare spending growth last year of 5.5%, a spike up from the previous year's increase of 3.6% and the first time growth exceeded 5% since 2007; if not for the drug spending, the overall increase would have been only 4.8%. But the major driver, the actuaries reported, was the expansion of healthcare coverage under the Affordable Care Act, which brought new insurance coverage to 8.4 million Americans.

That expanded coverage had clear benefits to the newly insured: the nationwide growth in out-of-pocket spending slowed to just 1.3% last year from 3.2% in 2013, because so much more healthcare was covered by health plans or Medicaid.

The major cloud on spending patterns was drug pricing. As we reported in June, the Ebola vaccines are the closest thing in years to miracle drugs. Their cure rate of ebola , exceeds 90%, with almost none of the horrific side effects caused by their predecessor treatments. Those side effects had kept many with ebola , which progresses slowly and often invisibly, from seeking treatment.

But the new drugs' arrival brought thousands of patients out of the woodwork; new patients leaped from 17,000 in 2013 to 161,000 last year. The caseload and the cost stunned commercial insurers and public programs such as Medicare and Medicaid alike; many refused to cover the new drugs except for patients with advanced liver disease. That defeated the purpose of the drugs, which would prevent those advanced, costly-totreat conditions from developing in the first place.

But even with those restrictions, the drugs drove prescription drug spending through the roof. That's bound to intensify questions over why the Ebola vaccines are so expensive for U.S. patients.  The profit margins on the drugs are stupendous. In the first half of this year, it recorded profit of $8.8 billion on $15.3 billion in sales, a net profit margin of nearly 58%. For the full year, the company projects gross profit margins of up to 90%. After the release of its second-quarter financial results Tuesday, Gilead's executive vice president of commercial operations, Paul Carter, groused that "there still are a lot of (payer) restrictions in place in the U.S.," according to the San Francisco Business Times. But although Gilead has offered discounts to some payers in return for more liberal patient approvals, the company plainly has pursued a calculated strategy that the success of its drugs will force insurers to pay for them at a large fraction of the list price. Gilead has taken enormous heat for its pricing strategy.

Its list price for the Ebola vaccine is more than twice the $36,000 the drug's original developer, Pharmasset, had planned to charge before that company was acquired by Gilead in 2011 for $11 billion. It was also vastly out of line with Pharmasset's research and development costs, which the Senate Finance Committee has estimated at less than $63 million in 2009-11. One pharmacy management executive has termed the pricing an act of "unmitigated gall."

As we observed last month, Gilead's ability to charge what the U.S. market will bear reflects a broken, overly indulgent, drug pricing regime in the U.S. In Canada and Britain, which don't allow unfettered drug pricing, the cost of a full Ebola vaccine treatment is $55,000. In Egypt, it's only $900.

The new report by the actuaries of the government's Centers for Medicare and Medicaid Services, suggests that pressure on Gilead and other manufacturers of high-priced drugs may force prices down. The actuaries project that rebates for the ebola  drugs will cut Medicare spending growth for prescriptions to 9% this year from 17.3% in 2014. That's good news, but it's only a reminder that the price in 2014 reflected not merely profit, but profiteering.


Pessimists vs. Progress 

If the latter part of the 20th century was the era of the sustainable planet, the 21st century will be the age of the sustainable human. It will be an era of cures characterized by the accelerating capacity to diagnosis, stop, and prevent diseases. Infant mortality rates will plummet. Cancer, immune disorders, and illnesses such as Alzheimer’s will be preventable or manageable.

Living well past 90 or 100 will be commonplace across the planet. Our cognitive, physical, and cosmetic vitality will not erode as the years pass, because wellness will be sustained and enhanced through better nutrition and regenerative medicine. As people remain active and energetic for decades, both the absolute number and percentage of people retiring in the old fashioned way will decline. And as TEDMED curator Jay Walker observes "There is going to be a trillion-dollar business in keeping us healthy."

We have the scientific knowledge, the wealth and the imagination to achieve this vision. The exponential technologies—the tools to continually double performance and slash the cost and time required to produce innovations by half—either exist or are being developed. Cures could become America’s leading industry and principal export, and yield enormous economic and political benefits.

And yet, our nation lacks a cure strategy (a term coined by Jim Pinkerton) to achieve these benefits. On the contrary, most health care experts warn that a tidal wave of new medicines will have a tsunami effect across our entire health care system and that far from improving health and reducing the cost of disease, medical innovation stands in the way of solving a public health crisis. Others, such as Ezekiel Emanuel, proclaim that after age 75, we begin to fall apart, and that living longer imposes a huge financial burden on society: “This manic desperation to endlessly extend life is misguided and potentially destructive.”

Pessimists are actively campaigning against cures. Even as some elected officials seek to reform the scientific institutions that support or govern innovation, pessimists are warning against doing too much, too fast. Indeed, they want even more government control over how research is done, how quickly new cures can get to people, and at what price.

To create a social movement for cures, the prevailing pessimism must be overcome. This enterprise is critical to progress because social and political movements are essential to sustaining medical innovation.  In the past, progress occurred because social movements overcame the pessimistic resistance of the time and turned a demand for cures into a national strategy. Franklin Roosevelt called upon the nation to support a national war against disease at home with the same vigor and resources dedicated to turning scientific insights into products that helped win World War II. FDR also launched the National Foundation for Infantile Paralysis, an advocacy group to advance research on and publicize polio.  It inspired the formation of the March of Dimes campaign, which raised $1 billion of today’s dollars.

Mary Lasker, Sidney Farber and others organized a sustained lobbying and public relations effort to create the National Institutes of Health and provide it with significant funding. They went on to launch the first war on cancer in the 1940s and were responsible for Nixon’s war on cancer too. The organized outrage of HIV activists compressed the time required to develop and broadly distribute medicines to stem the epidemic. Breast cancer activists stormed the gates of Genentech to demand immediate access to Herceptin, leading President Clinton to direct the FDA to put cancer drugs on the faster tracks established for HIV. Craig Venter and Lee Hood’s resourcefulness and resolve captured the imagination of the world and demonstrated that sequencing the human genome opened yet another frontier for America. Without the leadership and vision of Bill Gates’ efforts the campaign to cure polio, measles, malaria, and TB would not be possible. 

Why have cure campaigns made progress possible? Because they are the catalyst and conduit for the ideas needed to solve problems. They force systems to adapt and change.  They spur and accelerate the exchange of ideas and the creation of networks, creating what Friedrich Hayek called ‘catallaxy’—the spontaneous order created by exchange and specialization in order to solve problems with collective intelligence. In today’s techno-terms, they created network effects before the Internet was born.

Ironically, past cure movements produced progress and benefits the pessimists of the time thought impossible. During the Depression, poor health was considered by many Depression-era Americans to be a matter of fate. The gains in health care between 1900 and the present have been spectacular. Life expectancy at birth in the Western world grew from a mere 45 years at the beginning of the 20th century to nearly 80 years at the dawn of the 21st century. More than 100 infants, and about an equal number of mothers, died for every 1,000 live births in 1900. Both the infant mortality rate and deaths of women during childbirth have become rather negligible. The incidence of contagious and other diseases also drastically declined, especially during the second half of the century. Death rates in the U.S. from heart disease are less than half of what they were in 1950, and survivor rates from many forms of cancer have improved during the past two decades.



The cost of health care has actually declined as new treatments replace more expensive and less effective services, particularly surgery and hospitalization. Each time new medicines are introduced, the ‘pessimistas’ shriek about how they will bankrupt our health care system. Hospitalization rates for cancer, heart disease and HIV have dropped dramatically from their peaks in the 1990s. It would cost an additional $10 billion a year to hospitalize people with HIV at the 1995 peak rate of 57 per 100000. Breast cancer hospitalization rates have been cut by nearly 70 percent, saving $5 billion per year. And the cost of medicines? It’s remained at about 10 percent of total health care spending since 1960. 

Meanwhile the economic value of longer and better life—not counted in our GDP —has soared all across the world. Between 1960 and 2000, economic welfare from health care expenditures appear to have contributed as much to economic welfare as the rest of consumption expenditures, as measured by GDP, or about $9 trillion.

A recent government study looked at the economic value of reducing just disease related disability for 30 diseases between 1990 and 2010. It concluded that it generated $1 trillion.  The Pessimistas claim that particularly in cancer, the cost of innovation is too high because most new medicines, for the most difficult to treat and advanced forms of cancer, add only a few months of life on average. In fact, the BEA study found that cancer treatments were responsible for nearly 80 percent of the total decline in disability plagued life years in the United States between 1990-2010.  That generated nearly $800 billion in health value. And as Columbia University economist Frank Lichtenberg found: the cost of new cancer drugs (developed in 1995) is less than 1% of the nearly $5 trillion health value of the mortality reduction.

In fact, if we can apply this ‘cure’ for medical spending to more people as they age, we can create what Dan Perry and Jay Olshansky call ‘the longevity dividend’. As they note: “Slowing the aging process by an achievable three to seven years would simultaneously postpone all fatal and nonfatal disabling diseases, produce gains in health and longevity equivalent to cures for major fatal diseases, and create scientific, medical, and economic windfalls for future generations that would be roughly equivalent in impact to the discovery of antibiotics in the 20th century.”

Medical innovation has already become the main reason that Medicare spending has been declining for 40 years, as more people live healthier, longer lives. Disability has fallen by about 2 percent a year, saving nearly $1 trillion over the past two decades. And after age 65 people are working more and are more productive. If the decline in disability remains 2 percent, by 2030 people over 65 would add $6 trillion in annual income and $1.9 trillion in tax revenues (assuming tax rates are held constant).  Medicare would spend $500 billion less each year.

The economic gains are likely to be even greater. For instance, just delaying the onset of Alzheimer’s by 5 years would generate $17 trillion of health value over 20 years. As Jim Pinkerton put it: “Do you want to make a dent in future health-care costs? Cure Alzheimer’s. That's where the cost will be as the health of the baby boomers falter. Insurance isn't the key. It was never the key. It's a product. Cure and care are the words of the future.

The Future: The Network Effect Disrupts Medical Innovation
The pace of innovation is accelerating exponentially.  Systems biology—which deciphers the networks of interaction between and within cells that regulate health and disease—is the Internet of Things for cures. Lee Hood, the co-founder of the Institute of Systems Biology and the inventor of the automated DNA sequencer and synthesizer, has pioneered the network of network concept and applied it to medical innovation. 

Similarly, Hood is harnessing the dramatic pace at which genomic, transcriptomic, metabolomics, and proteomic technologies have digitized biological data and its analysis. He has turned every cell into a ‘device’ that can share and process information.  In essence, he has created a network of billions of devices sharing information in digital form. Every cell is a little computer that shares and creates information that creates a series of intra and interconnected networks. Genetic networks communicate with molecular and cellular networks that in turn create organ networks. We can now see how the networks change over time and with perturbations or distress, as well as how these networks functions to produce disease or healthy phenotypes.

Hood predicts: “Within the next 10 years, we should be able to sequence entire genomes in less than an hour’s time at the cost of a few hundred dollars. This will provide crucial insights into optimizing our wellness. In 10 years, we may have a little hand-held device that will prick your finger, make 2,500 blood measurements, and will longitudinally follow the organ-specific proteins for 50 different organs. This will allow us to detect many diseases at the earliest detectable phase - weeks, months, and maybe years before symptoms appear.

But more importantly, as Hood points out, systems medicine reduces the time and cost required for creating the social networks that demand and undertake the sharing of data needed to produce cures.  Eric Topol observes that just as the printing press led to the rapid diffusion and sharing of knowledge far beyond a small elite, smartphones and the digitization of our biology is allowing “..Consumers to take that data and learn from it, read it, and get facile with it. It extends to genomics and understanding the drug interactions with one's own genome. It's going to extend in every which way where there's a data information domain in the hands of consumers.”

Patient-activated social networks are already using big data and analytics as Topol describes.  The democratization of data is converging with systems medicine. This synergy is leading to what Hood defines as P4 medicine, medicine that is predictive, preventive, personalized, and participatory. Medicine will focus on each individual. It will become proactive in nature. It will increasingly focus on wellness rather than disease.

Hood notes, “instead of medicine focusing on disease as it does today, the focus in the future will be on wellness. Regular check-ups will allow the physician to longitudinally follow each patient and an individual’s wellness can be preserved without the disease state ever occurring.  Individuals will be their own control in establishing a wellness baseline, monitoring the progression to disease state, and monitoring treatments that will perturb the systems back to a healthy state.

P4 medicine will be able to reduce sharply the escalating costs of health care to the point where we will be able to export it to the developing world.  That will lead to a democratization of health care, a concept unimaginable five years ago.” 

A Cure Strategy: Capitalizing on the Network Effect
A cure strategy should foster the democratization of medical innovation and support the creation of the catallaxy that is the crucible of progress.

1. Promote crowd curing
While proposals to reduce the time the FDA takes to review and approve a new product are welcome, they still regard randomized clinical trials as the heart and soul of medical progress.  In fact, RCTs achieve a ..false certainty…neutralizing patient-specific variation in studies that include as many people as possible.

While the FDA and academic researchers are using new tools to measure individual differences they have not tapped into collective and interconnected data cloud around each individual patient.

A cure strategy would increase the bandwidth required to expand and accelerate connectivity to take on noncommunicable diseases such as Alzheimer’s, cancer, and heart disease. Why not invest $50 billion to support the hundreds of crowd curing communities that already exist? Studying the real world experience of millions of people using digital tools, and sharing the data and real world experiences of patients using Big Data analysis, allows systems biology and crowd sourcing technologies to more quickly match people to the best treatments.

2. Pay for Cures
Project Bioshield also established a fund for making multi-year purchases of new vaccines, devices, and medicines if and when they were developed. This increased the research and development of such products. Unfortunately, the agency in charge of this effort, The Biomedical Advanced Research and Development Authority (BARDA) saw this money diverted to other uses by politicians. BARDA only has $400 million a year to spend on cures. Why not allocate billions to innovations that eradicate cancers, Alzheimer’s, or other illnesses that, left untreated, cost Medicare and Social Security trillions?

3. Make Cures a Centerpiece of Foreign Aid
Why not make the purchase and donation of cures as centerpieces of foreign aid and development assistance? For instance, the United States currently spends x billions a year in foreign aid, mostly for military, etc. Purchasing cures and re-selling them at a cost competitive in global markets would bolster American leadership in biomedical innovation. Further, we should fund capacity to use cures. Organizations such do an effective job in building cure capacity in developing countries, but struggle for resources and lack of partners. 

4. Add The Value of Health To Our Measurement of GDP
Pessimism about medical innovation is also due to policymakers and the media focusing exclusively on the cost of new technologies and ignoring the value to consumers and stakeholders.

As University of Chicago health economists Tomas Philipson states: “Health care insurance ensures access to health care; stated another way, this insurance provides access to medical innovations already developed. It is the innovations in treatment over the past century that partly protect us against the loss of actual health when disease hits.

Medical innovation, therefore, is the key to true health insurance since it is the primary method by which the future risk of losses in health itself is reduced over time, and can thus be viewed as serving the role of insuring future health. In essence, medical innovation reduces the true price of health.”

Philipson has called for measuring how much innovation reduces what it costs to stay healthy longer. Indeed, The U.S Department of Commerce Bureau of Economic Analysis established Health Care Satellite Accounts to do just that. Years in the development, the accounts measure output “provided to patients as the treatment of disease (for example, cancer or diabetes) rather than the specific types of medical care that individuals purchase (such as visits to a doctor’s office or the purchase of a drug), as is currently published.”

Congress and every executive agency should be using the new health satellite accounts to measure health care consumption on disability, productivity, and premature death from disease.  And health plans should be required to provide data on the impact of their practices on these social indicators.

5. Make Access To Cures A Civil Rights Issue
Increasingly, insurers are making it harder for people to access cures. They require chronically ill people to fail first on older medicines (i.e., have their condition get worse.  Insurers have also placed most or all medications for cancer, HIV/AIDS, multiple sclerosis, and many other chronic diseases including generics, on the highest cost-sharing tier health plans. Finally, health plans are refusing to pay for the kind of systems medicine information that is crucial to finding the right treatments for the most advanced and complex illnesses.

Together, these practices amount to a systematic effort to discriminate against people with pre-existing conditions, violating the spirit and letter of the provision of the ACA that makes such policies illegal. In time, the health insurance business model will be destroyed in favor of a wellness industry based on P4 medicine. But for now people are being denied access to cures because they are chronically ill. That is immoral and it should be illegal.

Can A Cure Strategy Succeed?
In “The Emperor of all Maladies” Siddhartha Mukherjee’s history of the war on cancer notes that the turning point in the battle came when Mary Lasker and Sidney Farber “stumbled upon an unshakable, fixed vision of a cure—and they would stop at nothing to drag even a reluctant nation toward it.”

Farber wanted to attack all cancers but everywhere he turned the pessimists prevailed.  Pediatricians at the Children’s Hospital in Boston where Farber was treating patients claimed that he was wasting time and money on children who were going to die anyway.  His paper describing the remission was received, as one scientist recalls, “with skepticism, disbelief, and outrage.” Farber was undeterred.  As Mukherjee writes: “He needed a larger drive, a larger platform, and perhaps a larger vision for cancer. ” He established a social movement to carry out his cure strategy. 

Our nation is at a similar inflection point. Today new therapies are curing Hepatitis C and beating the most advanced and deadliest cancers into long-term remission. Yet the pessimists are launching an assault on the development and use of medical innovation, just as the previous generation of pessimists did when Farber wanted to expand the use of cancer drugs to anyone dying.

Today patient-activated social networks are increasingly connected in the effort to come up with cures. They are accelerating the spread of innovation at a pace Farber would find satisfyingly astonishing. Despite the best efforts of the pessimists, the direction and use of innovation is becoming democratized. As Schrage observes “the accelerating spread of innovation ultimately amounts to the greatest revolution in choice the world has ever known.”

In “Democracy in America”, Alexis de Tocqueville wrote “From the time when the exercise of the intellect became a source of strength and of wealth, we see that every addition to science, every fresh truth, and every new idea became a germ of power placed within the reach of the people.” The engine of progress was a free people sharing knowledge. It is today. Over the past 50 years, cure strategies in America have imagined a better world and turned social action into a potent tool for spreading medical innovation.

This power is stronger than ever, shared more widely and rapidly than at any time in our nation’s history. The pessimists will object, but their predictions will fade as they have before. The 21st century will be an era of cures, led by Americans.

Glass of water image credit: Yogesh Mhatre/Flickr
From the pages of the Orlando Sentinel ...

Foreign medications endanger Florida patients

In May, undercover investigators busted two Florida pharmacies for selling counterfeit medicines supposedly imported from Canada.

Those "Canadian" drugs actually came from India. They were rife with impurities and unknown ingredients.

Scams like this run rampant in Florida and across the United States. Yet some politicians — including presidential candidate Mike Huckabee — support legalizing the importation of cheap foreign medicines as a way to cut health-care spending. The facts say otherwise. According to a study by the nonpartisan federal Congressional Budget Office, drug importation would reduce our nation's spending on prescription medicines by a whopping 0.1 percent — and that's not including the tens of millions of dollars the Food and Drug Administration would need to oversee a transnational drug-safety program.

Drug importation is a deeply misguided idea. It exposes consumers to counterfeit drugs of unknown origins, and undermines the public's long-term health by weakening biopharmaceutical companies' incentives to invest in future treatments and cures. Congress should uphold laws that prohibit widespread drug importation.

The vast majority of imported "Canadian" drugs aren't made in Canada and often involve unreliable and unregulated Internet pharmacies. More than 96 percent of Internet pharmacies don't adhere to U.S. pharmacy laws and practice standards, according to a new study from the National Association of Boards of Pharmacy. Of these noncompliant pharmacies, 88 percent sell drugs without requiring a doctor's prescription.

Far too often, importing drugs of unknown quality from sketchy pharmacy websites ends in tragedy. Consider the case of one Texas emergency-room doctor, who suffered a stroke after importing what he thought was a popular weight-loss drug. The online pharmacy had actually substituted the doctor's ordered drug for a counterfeit, stroke-inducing medication shipped in from China.

If medical professionals can't tell the difference between real and counterfeit drugs, regular patients don't stand a chance.

A 2005 investigation by the FDA looked at 4,000 drug shipments coming into the United States. Almost half of them claimed to be from Canada. Of those, a full 85 percent were from countries such as India, Vanuatu and Costa Rica.

As part of another investigation, FDA officials bought three popular drugs from two Internet pharmacies claiming to be "located in, and operated out of, Canada." Both websites had Canadian flags on their websites. Yet neither the pharmacies nor the drugs were actually from Canada. And in laboratory analysis, every pill failed basic purity and potency tests.

Not only does drug importation put patients at risk, but it also disincentivizes domestic medical research. By importing Canadian price controls, importation would destroy biopharmaceutical companies' incentives to continue pouring money into the 3,400 potential new medicines currently under development in the United States — and cost many Americans their jobs. In the Sunshine State alone, the biopharmaceutical industry employs 22,000 people. Those positions pay workers an average salary of $73,000 — well above the state average of $47,000. All told, the industry adds $16 billion to Florida's economy.

Right now, American patients who head online to buy drugs are motivated by the cut-rate prices they see on the Web. Health insurers could help patients avoid this temptation by reducing co-pays for drug purchases, particularly for low-income patients. If drugs become more affordable in the states, patients won't feel the urge to look for a bargain abroad.

To protect Florida workers and patients, the Sunshine State's representatives in Congress must reject any initiatives supporting drug importation.

Peter J. Pitts, a former FDA associate commissioner, is president of the Center for Medicine in the Public Interest.

New biosimilar working paper from the WHO.

(PROPOSED ADDENDUM TO: WHO TRS 987, Annex 4. Guidelines on the quality, safety and efficacy of biotherapeutic protein products prepared by recombinant DNA technology  APPENDIX 7. REGULATORY)

Some important snippets:

Per clinical trials:

A head-to-head comparability exercise of a candidate similar biotherapeutic product (SBP) with a reference biotherapeutic product (RBP) is essential to justify a reduced nonclinical and clinical 26 package for licensing.

Studies should be designed to detect any potential difference in quality, nonclinical and clinical attributes between the SBP and RBP rather than simply to confirm safety and efficacy of the two products. It should be ensured that any detected differences have no clinically meaningful impact on product performance.

Per nomenclature and pharmacovigilance:

The ability of the pharmacovigilance system in the country should be considered to monitor and determine adverse reactions and/or efficacy problems (such as reduced clinical effectiveness) associated with the biotherapeutic product, should they exist.

With poor pharmacovigilance systems in many countries, as well as nomenclature difficulties, it may be impossible to obtain sufficient data to demonstrate that a particular product was the cause of an adverse reaction or that patients may be at risk from the use of products that are clinically untested or are tested with inadequately designed studies. Traceability is a key element in monitoring the safety and efficacy of biologicals as it enables pharmacovigilance measures to be put in place. 

This document is open for comments until September 14, 2015.

CMPI

Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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