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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 Westâs will to stand up to terror, writing about medical innovation or health care seems insignificant. But if it wasnât 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 â because they are American, multinational, profitable and founded on patent protection â 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 Partyâs 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 â 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. Thatâs 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 canât 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 â and the enemies of America and capitalism â that profit motives are whatâs 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 â 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.

The Vitter Twitter

  • 07.12.2006

Now that the AARP has said that the Part D benefit offers better discounts than unsafe and unregulated drugs from foreign websites, you’d think that the sideshow known as “drug importation” would find its rightful place deep within the dustbin of history. But, sadly, no. Alas some of our elected officials (in this case led by Senator David Vitter, R, LA) are still beating that particular drum.

“I don’t think … taking away small amounts of prescription drugs from seniors crossing back from Canada, et cetera, is the right thing do,” said Sen. David Vitter, a Louisiana Republican who sponsored the amendment to a Department of Homeland Security funding bill.

Senator Vitter doesn’t want a discussion he wants a soapbox, because he knows the facts — that uninspected, unregulated foreign drugs are unsafe and illegal — make his oratory vacuous. If he doesn’t know then he’s deaf, dumb, and blind.

This is a recording.

Unfortunately his is a chorus backed by a supportive media echo chamber. But the music is out of tune and increasingly out of touch.

Here’s what Senator Vitter is complaining about — recently the FDA launched an investigation confiscating thousands of drug shipments headed for the U.S. When opened, nearly half claimed to be of Canadian origin but, according to FDA investigators, 85 percent of them were from 27 other countries such as China, Iran, and Ecuador. And 30 of the drugs were counterfeit.

Facts are stubborn things.

If you are looking for media attention, please leave your name at the sound of the beep.

Here was the Headline:

Drug Interactions
Financial Ties to Industry
Cloud Major Depression Study

At Issue: Whether It’s Safe
For Pregnant Women
To Stay on Medication
JAMA Asks Authors to Explain

The article, by David Armstrong of the WSJ, dramatically begins:

“For pregnant women considering whether to continue taking antidepressant drugs, a study in a February issue of the Journal of the American Medical Association, or JAMA, contained a sobering warning: Stopping the medication greatly increases the risk of relapsing into depression……But the study, and resulting television and newspaper reports of the research, failed to note that most of the 13 authors are paid as consultants or lecturers by the makers of antidepressants.”

But the article, and the endless tongue wagging that followed, failed to note that most of drugs mentioned in the study are now available in generic form.

Oh.

That’s right folks. Big pharma and their hacks had nothing better to do than conduct research to advance the well-being of pregnant women suffering from depression knowing that the drugs in question were either off-patent or about to be. How is THAT possible?

The WSJ and Mr. Armstrong ignored the extensive literature looking at the genuine risks of treating depression to the fetus as well as the risks of not doing so. Not only are such women more likely to commit suicide or do harm to others, untreated depression during pregnancy itself is associated with impaired feto-placental function, premature delivery, miscarriage, low fetal growth and perinatal unwanted effects. Armstrong never looked at any other studies or cared to, just as he never looked at expiration dates on patents.

This article is nothing short of disgusting. It’s basis thesis is not even warranted by the facts but Armstrong goes along and eggs people into making comments that prejudge the research and researchers. Armstrong claims the study is clouded by financial ties to industry. But his article is devoid of even a nanobyte of objectivity. Whose judgement is clouded?


I am receiving lots of interesting emails from patients and groups who take exception to the piece in USA Today about the price of cancer drugs: The article, written by Elizabeth Szabo, parrots the approach formulated by Geete Anand at the WSJ both in terms of bias and sloppiness. It is of the “these drugs are hugely expensive and don’t add much to survival and these drugs are too pricey and people who are dying can’t afford them.” I have yet to figure out how drugs can be both ineffective and essential at the same time, but from Szabo’s rushed perspective being both just adds to the drama and criminality of having to spend, on average $1600 a year on cancer therapy.

The US spends about $24 billion on cancer drugs, less than is spent on cholesterol drugs and slightly more than ulcer medication. Total spending on cancer in the US is $75 billion. That means 32 percent of total spending on cancer is drugs, about average for chronic illness. Meanwhile the total cost of cancer to the US, including lost productivity due to death and illness is approximately $210 billion. By 2010, cancer drug spending will rise to about $55 billion. If we can limit use to those who can benefit the most and increase survival we save billions in productivity costs and quaity of life. Where was Szabo on all this?

1. The claim that most new drugs don’t “cure” cancer but just add a few months of life is meritless. To be sure the recent Tarceva and Gemzar trials showed no survival advantage, but they were genetically non-selective studies. There is no average cancer so there is no average response or survival rate. Many new targeted therapies increase survival signfiicantly for subpopulations precisely because they hit a specific pathway unique to a particular group. The substantial increase in life expectancy is masked by large clinical trials that include non-responders. For many, being disease free for five years with no tumor progression amounts to a cure. And that doesn’t include the cervical cancer vaccine.

2. Doesn’t quality of life matter? If you can life for two years without the horrible effects of cancer or chemotherapy and thereby stay at work, be in school, remain a parent, isn’t that worth something. Revilimid eliminates the terrible trauma associated with extensive and repeated blood transfusions which cost $60000 a year. What about the value of being able to treat the disease without such complications and disabling approaches.

3. Where is the responsibility of insurance companies to cover the cost of cancer medications. Why would it cover the cost of cheaper and less effective drugs but not Avastin or Herceptin? Indeed, tiered copays have been shown to discourage appropriate and cost-effectiveness use of medicines for diabetes and heart disease. Cancer is no exception. Companies should not have to shelling out money for medicines that insurance companies should be paying for.

4. Reducing cancer mortality by even 10 percent would generate over a trillion in productivity in America. Insurance companies might not gain, but we would.

Here’s the real question: Why doesn’t the media analyze the issue of new medical technology from this broader perspective and be more thorough in its investigation of clinical evidence prior to making such assertions as “higher prices but little added benefit.” And why does it focus on the price of medicines rather than the way in which price is used to ration access by health plans when the drugs themselves add significant value to the lives and wellbeing of Americans.

Es ist nichts schrecklicher als eine thatige Unwissenheit…That’s Goethe for “There is nothing scarier than an active ignorance.” Case in point, the most recent post on The Health Care Blog by someone named Maggie Mahar who managed to write over 800 words arguing that there too many cancer drugs in development. How does she come to this conclusion? By ignoring medical science and simply applying the old attacks on big Pharma to cancer research:namely that every single one of those drugs is simply a me-too medicine that offers no real survival benefit (note no mention of quality of life) Here’s what Maggie concludes about cancer drugs:

“As each drug company races to fill its own pipeline, a fragmented industry spawns a dizzying array of half-way cures. Too many drugs shrink tumors-but don’t bring any mortality benefit. Meanwhile, too much competition and too little collaboration makes it difficult for oncologists to sort out which drugs are most effective alone, which should be used together-and in what sequence. “

So in otherwords the explosion of targeted cancer drugs — which may or may not be used in combination — is causing too much choice and opportunity. And if the drug does not provide an everage survival benefit based on randomized clinical trials — regardless of whether subpopulations are helped or whether quality of life is enhanced — get rid of them. So the right response is to just cut down the number of drugs in development?

Let’s be clear, the rate limiting factor here is not that too many drugs for cancer, Alzheimer’s, Parkinson’s or infectious disease in development (is 100 too many? 50? What about phase III failures?) but the need to better understand underlying disease mechanisms and pathophysiology and link it to dose and drug response. Do you get the sense that Maggie understands any of this? She has written a book that makes the earth shattering discovery that medicine is fraught with….uncertainty!!!! Well ,targeted therapies are a direct result of how science provides the tools to do so, particular by eliminating the one size fits all approach to evidence based medicine that Maggie swoons over. A dizzying array of drugs? Only to those who fail to use new tools of analysis and are too lazy to advance the state of care. Or to journalists who think that average response to drugs is good enough or the only measure of well-being.

I am so sick and tired of health policy wannabes recycling the same old accusations about drug development and health care without even paying attention at the impact technological transformation plays in shaping the future. You can see that there have come to a conclusion shaped by ideological biases and then work backward.. Maggie Mahar is just one more uninformed health care conspiracy theorist who trashes medical progress without knowing of what it consists….

A Blogger's Banquet

  • 07.10.2006

Wither pharmaceutical blogging? Have a look at the attached article on the “New Frontier” of pharmaceutical communications and one of its feisty evangelists … me.

Here’s the link:

http://www.bizjournals.com/sanfrancisco/stories/2006/07/10/newscolumn5.html

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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