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May 10, 2000: Senator Byron Dorgan co-sponsors the following amendment:
“NONINTERFERENCE. — In administering the prescription drug benefit program established under this part, the Secretary may not — (1) require a particular formulary or institute a price structure for benefits; (2) interfere in any way with negotiations between private entities and drug manufacturers, or wholesalers; or (3) otherwise interfere with the competitive nature of providing a prescription drug benefit through private entities.”
Six years and 180 degrees later …
July 2006: Senator Byron Dorgan plans to offer the following amendment:
“REQUIREMENT TO NEGOTIATE PRICES WITH MANUFACTURERS. — In order to ensure that each Part D individual who is enrolled under a prescription drug plan or an MA-PD plan pays the lowest possible price for covered Part D drugs, the Secretary shall negotiate contracts with manufacturers of covered Part D drugs, consistent with the requirements of this part and in furtherance of the goals of providing quality health care and containing costs under this part.”
Yep — Senator Dorgan was for it before he was against it.
As Lord Byron wrote, “I’ll publish right or wrong. Fools are my theme, let satire be my song.”
Here are the facts behind the posturing:
The CMS chief actuary has already rejected the idea that Federal “interference” will save money:
“In considering these issues, we believe that direct price negotiation by the Secretary would be unlikely to achieve prescription drug discounts of greater magnitude than those negotiated by Medicare prescription drug plans responding to competitive forces.”
And the CBO has made a similar determination:
“We estimate that striking [the non-interference] provision would have a negligible effect on federal spending because CBO estimates that substantial savings will be obtained by the private plans and that the Secretary would not be able to negotiate prices that further reduce federal spending to a significant degree.”
The fact is that robust competition among Medicare Drug Plans continues to drive down costs for beneficiaries and taxpayers, while stimulating enrollment.
* According to CMS, the net total cost of the drug benefit to the federal government over the next decade is about 20% (or $180 billion) lower than the total cost estimated last year.
* The vast majority of this reduction is the result of lower-than-expected drug costs and higher-than-expected price breaks negotiated by Medicare drug plans. According to CMS, data from Part D plans demonstrate that rebates and discounts on drugs are much larger than originally projected.
When’s the last time a government-negotiated program delivered such numbers?
According to government experts, eliminating “noninterference” won’t save money, but it will lead to government price controls and a government controlled benefit.
CBO has found that multiple, competing private sector plans contain costs more effectively than a government-controlled benefit through competition and plans’ use of price discounts, rebates, and other tools. (Surprise! Everything you learned in Econ 101 was right.) The noninterference provision protects this approach by preventing government bureaucrats from getting in the way of these negotiations.
Repeal of the noninterference provision would also repeal the prohibition on the government setting a national, one-size fits all, formulary. Yikes!
According to CBO, allowing the government to negotiate prices may not result in current VA prices for Medicare Part D — The VA Health Care System is a public health system with statutory price controls and other special arrangements representing a very small share of the market.
For more on why VA is not a better way, please see my previous blog (“VA is not the way,” 3/13/06).
Bottom line? The Medicare Drug Benefit gives Medicare beneficiaries the same negotiating power that works for Members of Congress and 190 million other Americans.
Federal interference was a bad idea when Senator Dorgan was against it in 2000. And it is still a bad idea now that he is for it in 2006.
Competition works. Politics gets in the way.
To once again quote Lord Byron, “Always laugh when you can. It is cheap medicine.”
And, methinks, Lord outranks Senator.
NPR’s Joanne Silberner has an informative and compassionate look at the progress — so far — of the use of pharmacogenomics in improving drug prescribing in her broadcast today. The link to the podcast and excellent FAQ about personalized medicine is posted below. She, along with Cathy Arnst of Businessweek and Anne Underwood of Newsweek have provided solid coverage of this field.
Remember the Madonna video?
Vogue. Strike a pose.
That’s what’s behind the ill-considered and dangerous Vitter amendment that would neuter US Customs and Border Protection from actually protecting US citizens — by removing their authority to seize illegal, potentially unsafe and counterfeit prescription drugs that Americans import “from Canada.”
“From Canada?” Not necessarily.
All of the large Canadian internet pharmacies openly admit that the drugs they send to unsuspecting Americans are not “the same” drugs that Canadians get at their local pharmacy. They’re from other places — many from Europe. So what’s wrong with that? Two words — parallel trade — the term Europeans use for drug importation. Senator Vitter may only want drugs “from Canada” — but that’s impossible — because EU law makes it so. According to the Treaty of Rome, parallel trade is completely legal and Articles 30 and 36 prohibit manufacturers from managing their European supply chains in their own or patients’ interests.
Sorry Senator, the truth is inconvenient.
Last year 140 million individual drug packages were parallel imported throughout the European Union — and a secondary wholesaler repackaged each and every one. (The same type of secondary wholesaler that we are trying to eliminate in the US because of their role as “weak link in the chain” — the chain of custody that is.)
This means that, literally, parallel traders in Europe open 140 million packets of drugs, remove their contents and repackage them. But these parallel profiteers are in the moneymaking business, not the safety business. And mistakes happen. For example, new labels incorrectly state the dosage strength; the new label says the box contains tablets, but inside are capsules; the expiration date and batch numbers on the medicine boxes don’t match the actual batch and dates of expiration of the medicines inside; and patient information materials are often in the wrong language or are out of date. Oops.
Vogue. Strike a pose.
This means that drugs purchased from a British pharmacy to an unknowing American consumer (or a blissfully ignorant United States Senator) could come from European Union nations such as Greece, Latvia, Poland, Malta, Cyprus, or Estonia. In fact, parallel traded medicines account for about 20% (one in five) of all prescriptions filled by British pharmacies. In the EU there is no requirement to record the batch numbers of parallel imported medicines, so if a batch of medicines originally intended for sale in Greece is recalled, tracing where the entire batch has gone (for example, from Athens to London through Canada to Indianapolis) is impossible. Caveat Emptor is bad health care practice and even worse health care policy. Safety cannot be compromised, even if the truth is inconvenient.
No time to Vogue.
From today’s Washington Times…. The Vitter amendment is a shameful reflection on the political instincts of the Senator who sponsored it. But it also reflects poorly on the collective judgment of those members who voted for it without considering the signal it sends our enemies and more importantly, those courageous law enforcement agents who have risked their lives to make America and the medicines they take safer.
Counterfeit drugs and border security
The Washington Times
USA, 7/19/2006 - On March 29, the federal Joint Terrorism Task Force unsealed an indictment charging 19 persons with operating a global crime and terrorism ring spanning Lebanon, Canada, China, Brazil, Paraguay and the United States. The ring sold counterfeit drugs and other contraband materials, largely through direct consumer shipment from Canada, to Americans seeking cheaper drugs. It, in turn, directed its profits to support of the criminal terrorist group Hezbollah.
Less than four months later, as Hezbollah rockets rained down on Israel, the Senate voted for an amendment offered by David Vitter of Louisiana to ban U.S. Customs and Border Protection agents from seizing prescription drugs that Americans import from Canada. For Mr. Vitter, the passage was a defeat of sorts: He wanted to ban Customs agents from seizing medicines imported from anywhere, which suggests that the politicians who voted for the measure knew that dangerous people were trying to sell fake drugs in America.
How they deluded themselves into thinking that banning law enforcement from seizing drugs purchased from Canada would not be like creating a safe haven for terrorists is another question. Indeed, Canada is already the favorite port of call for fake medicines. According to customs, most of these drugs are not shipped through wholesale distribution channels but are shipped directly to consumers, with Canada being the major transshipment point because of its access to the U.S. market
In 2003, the FDA and Customs confiscated thousands of drug shipments headed for the United States. When opened, nearly half claimed to be of Canadian origin, but, according to FDA and Customs officials, 85 percent of them were from 27 other countries, such as China, Iran and Ecuador. And 30 percent of the drugs were counterfeit.
Banning Customs enforcement is tantamount to giving terrorists a free pass to flood America with fake and dangerous drugs. Customs and Border Protection is the largest investigative arm of the Department of Homeland Security. It plays the leading role in targeting criminal organizations that produce, smuggle and distribute counterfeit pharmaceuticals. Hence, Mr. Vitter and the Senate are handcuffing Customs from policing the very trafficking corridors that Hezbollah and gangsters use to penetrate our borders.
According the NY Times today, David Graham who is to rational evaluation of the risks and benefits of medicine what Hezbollah is to advancement of peace in the Middle East, called for the withdrawal of Ketek based on the fact that others in the FDA’s infectious disease division relied on post market data from Europe submitted by the company. That’s pretty funny considering Graham has called for the removal of Crestor, Celebrex, Accutane, Rice Krispies and tap water based on post market data.
Graham is not alone is his obsessive pursuit of Ketek. He is joined by an FDA staffer who wondered in a memo whether the risk of liver failure was worth one less ear infection in regards to a Ketek trial. Well, as I wrote before, if that is the benchmark, we shouldn’t give anyone tylenol for a fever.
“David Shlaes, an expert in infectious disease and antibiotic research with the development of a new medicine under his belt has sent this email to me in response to the recent articles about Ketek’s “dangers”
Recent press reports on the development, approval and subsesquent reports of toxicity of the antibiotic Ketek have me concerned. … The implicit (if not explicit) message was that the evil pharmaceutical company submitted flawed data to the FDA who, admitting the study was flawed, still approved the drug in spite of serious safety concerns. Now patients are dying because of the greed of Sanofi and incompetence or worse at the FDA.
.. Ketek, an antibiotic developed by Aventis, now Sanofi-Aventis, was reviewed by the FDA in 2001. They noted safety concerns, partly around the potential for liver toxicity, and requested additional safety data. Aventis then carried out an extremely large study of over 24,000 patients using more than 1800 different investigators worldwide. This was the study (no. 3014) where the FDA noted that the study was so flawed that they could not rely upon its data. Nevertheless, the FDA noted that in the post-marketing experience with Ketek worldwide during the intervening years until 2003, almost 4 million courses of therapy had been prescribed with no clear safety concern, plus there was a general lack of a safety signal in the 24,000 patients in the flawed study. Therefore, the FDA approved the antibiotic.
FDA conducted a thorough review of adverse events related to Ketek in the post-market setting. They were able to identify 12 cases of acute liver failure of which four were fatal among 10 million prescriptions. There were 23 cases of liver toxicity overall in the data set. As a result of these findings, the FDA approved label for Ketek has been changed to note in bold letters the possibility of severe liver toxicity Ã¢ a reasonable approach based on the data.
Congress, specifically representatives Markey and Waxman, both democrats, and Senator Charles Grassley, a republican, have sent inquiries to the FDA regarding the approval of Ketek. Apparently, they believe that Ketek should never have been approved, and that the FDAÃ¢s approach to the entire problem has been flawed. Some have demanded that Ketek be withdrawn.
I would like to try and put all this in some perspective. To me, KetekÃ¢s story is one of risk and benefit and the risk tolerance of American society and the FDA. Let us take an old reliable antibiotic or even two or three Ã¢ penicillin, amoxicillin and augmentin. These antibiotics are very closely related, generic, inexpensive and are taken by many more millions of patients, including and especially children, than take Ketek. Augmentin, a combination of two penicillin-like drugs, had peak year sales of well over $2B at one point and may be the biggest blockbuster antibiotic in the history of the pharmaceutical industry. Penicillin is thought by most physicians to be the most safe and effective antibiotic ever to be developed and marketed. Yet the penicillin drugs can be expected to cause a fatal allergic reaction once in every 35-100,000 courses of therapy. Therefore, among the 10 million courses of therapy as surveyed for Ketek and for which 4 fatal cases of liver toxicity were identified, we could expect 100 to 285 deaths if the prescriptions had been for any of these penicillin drugs. In the FDA approved labeling for the penicillin drugs, the possibility of serious or even fatal allergic reactions is noted, just like the possibility of liver toxicity is noted in the Ketek label. Aspirin probably causes 7,000 deaths and 76,000 hospitalizations a year in the United Sates.
I wonder if, given our concern over Ketek, penicillin would even make it to the marketplace today, or if it were approved, whether it would be withdrawn shortly afterwards as reports of fatal anaphylactic reactions started to arrive at the FDA. Could we register asprin? Or, would we rely on the information already included in the approved product label noting a risk of rare but serious allergic reactions? Is Ketek different from penicillin? Would there be congressional hearings pillorying the FDA for approving or not forcing the withdrawal of penicillin?
I think its time for all of us, the press, Congress and the American public to take a step back from this brink Ã¢ for the brink it is. More large pharmaceutical companies have halted their antibiotic research efforts than the number that still continue working in the area. Among a large number of reasons for this pullback is the increasing stringency and cost of clinical trials required for registration Ã¢ of which Ketek is an example. If we want to have continued new and beneficial therapies from the pharmaceutical industry, in particular, if we want to have new antibiotics that fight infections resistant to the old antibiotics, we need come to a realistic understanding of the risk we are willing to accept.”
Covering less effective drugs
USA TODAY’s story implies that because most new drugs don’t “cure” cancer for most patients, they shouldn’t be so expensive. In fact, from 1975 to 1995, new cancer drugs increased the life expectancy of people diagnosed with cancer by about one year. From 1995 until today, death from cancer has been declining faster than at any other time in history.
USA TODAY bases its assertion that most new drugs don’t extend life on studies that tested drugs designed for specific groups from the results of one-size-fits-all studies. But lives are extended and enhanced by matching the right drug to the right patient well before the disease advances.
Maybe someone should have looked at an earlier USA TODAY story titled “Experimental drug stuns cancer doctors” (News, May 16, 2005). It describes Revlimid, which costs thousands a month and is a drug that targets a certain genetic mutation that causes a hitherto incurable blood disorder more common than leukemia is. Revlimid is nearly 100% effective in two-thirds of patients with the disease. It eliminates ineffective, equally expensive and debilitating blood transfusions.
USA TODAY wonders why people have to shell out money for cancer drugs. It should have asked why health plans cover the entire cost of cheaper and less effective drugs but not Avastin.
Robert Goldberg, Vice President
Center for Medicine in the Public Interest New York
William Tucker today has a great column in OpinionJournal discussing an interview with Andy Kessler, the author of The End of Medicine, with a particular emphasis on the amazing impact of advancing technology in terms of early diagnosis of disease and chronic conditions. Not emphasized heavily—-but clearly implicit within the topic—-is the complementary role of pharmaceuticals in the early treatment and cure of such diseases and conditions discovered early. It does not take a rocket scientist to foresee a large component of medical care as early diagnosis and then cure by pharmocology. Nor does it take a genius to see the dark clouds hovering over that bright landscape as a result of price controls, bureaucratic footdragging, and other such policy impediments, yet another shining achievement of Beltway magic.
Retrospective analysis of claims data to evaluate outcomes. Comparative evaluation of similar treatments to determine which approach cost-effective Shifting public and private dollars to the lowest-cost providers to reign in health care spending. That’s the gist of the so-called “evidence-based” medicine movement which has spread like the Hanta virus through hospital, managed care and state policy circles to create price-based prescription drug formularies that limit or encourage the use of lower priced medicines based on these sorts of exercises described above. Managed care and liberal thinks have been particularly aggressive in supporting EBM and has helped fund the Oregan center that is cranking out studies demonstrating that no one medicine is any better than any other for most people.
Now these same groups are howling now that they Medicare is giving them a taste of their own medicine. According to the NY Times (and I have will have to come to my own conclusion after further research) Medicare is developing a a new system of payment “… based on hospital costs, rather than on charges, and would be adjusted to reflect the severity of a patient’s illness. ” But the data for doing so will be based on a retrospective analysis of claims data which by definition cannot keep up with changes in technology. Hospitals and managed care plans are complaining — and so are some member of Congress probably prompted by the same interests — because they are afraid it will cut reimbursement for many procedures and technologies. A sample of the comments:
J. Brian Munroe, vice president of WellPoint, one of the largest private plans, said he feared that the Medicare changes “will introduce a significant amount of disruption to the commercial health insurance marketplace, driving up health care costs and causing marketplace confusion.”
Dr. Alan D. Guerci, president of St. Francis Hospital in Roslyn, N.Y., said the new formula would cut Medicare payments to his hospital by $21 million, or 12 percent. “It will significantly reduce payments for cardiac care and will force many hospitals to reduce the number of cardiac procedures they perform,” Dr. Guerci said.
According to the NYT…”drug and device makers have been lobbying Congress and the Bush administration to delay the changes to allow further analysis. Device makers are scheduled to meet with top White House officials this week. More than 200 members of Congress have signed letters supporting a one-year delay. “
But I thought evidenced based medicine was a good thing. Wellpoint was leading the way in integrated EBM into its formulary. Ditto Medicaid and many hospitals. Now, when the same interests who were using it to swing an axe at drug companies see that EBM is a double edge sword they are screaming for help and wringing their hands about horrible it is.
What’s the DRG for hypocrisy?
A hospital now receives the same amount for a patient with a particular condition, like pneumonia, regardless of whether the illness is mild or severe.
Against the backdrop of a war which is an obvious test of the WestÃ¢s will to stand up to terror, writing about medical innovation or health care seems insignificant. But if it wasnÃ¢t clear what the shaping impulse of CMPI and drugwonks is , maybe this is a good time to state or restate it now.
Medical progress has many enemies because many people regard the drug companies and biotech firms Ã¢ because they are American, multinational, profitable and founded on patent protection Ã¢ as evil. So therefore, many fail to separate out the benefits of progress from those that produce it. No different from the anarchists and communists that destroyed and appropriated the means of production and took the step of killing or diagnosing those who engaged in genetic research as insane because it conflicted with the PartyÃ¢s view that all equal in all respect. So therefore today governments push the notion of one size fits all medicine and cost-effectiveness for the group at time when effectiveness is a function of genetic differences that determine response to environment, lifestyle, medicines and disease.
There are those that twist science for their own political agenda. Some counterfeit medicines for profit. Some aid and abet counterfeiters Ã¢ who are usually gangsters and terrorists working together — by giving them a clear path to sell fake medicines to Americans by barring law enforcement from inspecting packages that in the past have been shown to be laden with adulterated pills. ThatÃ¢s our Congress folks! And the scientific stupidity extends to the stem cell debate, to those who shade and overstate studies on one side or the other not to advance discussion but to slam the other side. Moreover, it extends to the media that canÃ¢t take five minutes to do a Google search to determine if the expert they have on speed dial has any scientific substance behind them.
We have the tools and know-how to more effectively protect people against infectious diseases, bioterrorist threats. We have the capacity to eliminate inappropriate medical care. We have the ability to increase the value of health care by investing in information systems, medicines and decisionmaking tools that promote the prevention and prediction of disease. What we lack is the leadership and coalition of the wiling to accelerate a shift to the use of these advanced technologies and approaches.
Often the obstacle is the pessimism engendered by the tired old debate or critique advanced by the enemies of medical progress Ã¢ and the enemies of America and capitalism Ã¢ that profit motives are whatÃ¢s wrong with health care. This critique is simply a political tactic designed by those who want to exert their own control over the course and shape of medicine. They want to control the means of production. They want less profitable companies, different research agendas, different products, and different people in control over institutions critical to progress and ultimately want the government to make major decisions in health care.
The first strike of the anti-globalists and al Qaeda alike is the suppression of the creative energies of men and women wherever they seek to organize their energies to advance and enrich themselves, their families, and communities outside of authoritarian control. Without protection of intellectual rights and free markets therefore, the human condition diminishes.
A world that does not dare to defeat tyranny and evil when the opportunity arises Ã¢ or gives up, in the elusive quest for redistribution, the individual freedom to compete with and control what one creates will cease to exist.
Terrorists everywhere win by sowing fear. They achieve victory by getting people to give up and by believing there is no hope. The same goes for enemies of medical progress who seek to scare us into believing that only a purge of private sector research, government run health care and limits on patent protection with a goal of redistribution will save us from financial ruin and exploitation.
The enemies of medical progress ultimately have no vision of a better, healthier world. We at drugwonks hope to offer one by providing courageous examples and aggressively challenging lazy, unthinking and manipulative efforts to undermine the efforts of individuals to advance and commercialize medical insights. We are at the beginning of a new revolution in human health and productivity and we aim to support those involved in making it happen.
Major findings published this week in the Proceedings of the National Academy of Science. : A so-called “me-too” beta-blocker works best for people with a particular genetic mutation. The drug, called bucindolol doesn’t have much benefit to most people with high blood pressure. But for people whose blood pressure is channeled through a specific pathway affected by the Arg 389 gene and have a specific mutation also have a 40 percent higher reduction in mortality from heart failure. People who carry an entirely different gene would do worse on the drug.
The research — carried out and sustained over a decade by Mike Bristow of the University of Colorado and Steve Liggett, now of the University of Maryland — has been translated into both a drug and diagnostic. Media reports (The Washington Post) have stated that “it is unknown, for example, whether even those patients with the responsive gene would do better on bucindolol than on the two beta blockers already on the market for heart failure — a serious disease that kills half its victims within five years.” In fact, to the extent that the expression of the gene and disease is pathway specific — and the Bristow-Liggett research suggests that it is — no other drug would work better. Thus, CV treatments would follow the path taken by targeted cancer drugs.
So much for the effort to shove everyone into the cheapest drug based upon average response. Sometimes an older drug will have spectacular benefits for specific patients as a result of combining it with a diagnostic and sometimes the new medicine designed with a diagnostic in tandem will work better for another group. Evidence based medicine is being replaced by genomic-based medicine. The problem is policymakers and pundits still act and think as if the technology and informatics of healthcare is mired in the 20th century. It’s changing. And if ways of paying for and organizing and choosing healthcare don’t change in response, they become obstacles to better health.
You can read the publication online at the PNAS website: “A polymorphism within a conserved B1-adrenergic receptor motif alters cardiac function and a B-blocker response in human heart failure.