Health Business Blog

There’s a moving story about a man’s struggle with multiple sclerosis (MS) on the front page of today’s Wall Street Journal (After Diagnosis, A New Dilemma: What to Tell Boss?). Kenneth Bandler hid his disease from his employer because he was afraid he would be pitied at work and constantly asked about his condition.

The article reports that many MS patients leave the work force, “often long before disabilities required them to.” An expert cited in the article believes it may be due to cognitive problems that MS patients suffer.

I asked Dr. Robert Paul, a Brown University neuropsychologist who has studied MS and cognition, for his opinion.

One of the most common debilitating side effects of MS is fatigue. When people feel tired, they feel that they can’t perform well on cognitive tasks. But it turns out that their cognition doesn’t suffer as much as they think when they are tired.

We did a study where we gave MS patients a cognitive test, then a test designed to fatigue them, and then a followup cognitive test. MS patients did not perform quite as well as healthy controls on the cognitive tests at the beginning of the assessment, and they reported much more fatigue than controls. Further, MS patients reported significantly more fatigue after the work battery compared to controls , and they thought their cognition had suffered. But it turned out they did just as well on the followup cognitive test as on the initial one.” These findings suggest that fatigue may not have a significant additional impact on cognitive function in MS.

Part of the problem is a lack of sufficiently sensitive cognitive test batteries. Dr. Paul has been involved in the development of new, sensitive computerized batteries as part of the Brain Resource Company.

The reference for the study is Paul, R., Beatty, W.W., Schneider, R., Blanco, C.R., Hames, K. (1998). Cognitive and physical fatigue in multiple sclerosis: Relationships among self-report, objective performance and depression. Applied Neuropsychology, 5 (3), 143-148.

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PBMs such as Medco, Caremark, and Express Scripts manage pharmacy benefits on behalf of employers and health plans. They establish formularies of preferred drugs, negotiate rebates and discounts with pharmaceutical manufacturers and pharmacy networks, provide mail order services, and handle administrative details. However, it’s not clear that they lower costs for their customers, and the rebate agreements they have with manufacturers are not typically disclosed. (Matthew Holt at The Health Care Blog has written extensively on this topic.) Customer satisfaction is sometimes lacking.

Independence Health, a small health plan in New York State that dropped its PBM eight years ago, is launching what it calls a “transparent” PBM business model, in which it will pass along all of the discounts and rebates it receives and charge a straight fee-for-service to its customers. It seems unlikely that this move alone will shake up the PBM business, but it will be fun to see if there is an appetite for the new offering.

A March 25 article from Drug Benefit News on the topic was reprinted on AIS.

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In recent posts I’ve described two approaches to improving drug compliance and persistency: a device to prompt patients to take their medications, and more convenient dosing schedules. A survey by Harris Interactive for the Wall Street Journal illustrates that while those approaches are important they won’t solve the whole problem.

In the survey, 63 percent of the respondents had been prescribed drugs that were supposed to be taken on a regular basis during the past year. Of those, the majority reported at least some non-compliance. Top reasons cited for non-compliance were:

• Forgot to take(64%)
• No symptoms or symptoms went away (36%)
• Wanted to save money (35%)
• Didn’t believe the drugs were effective (33%)
• Didn’t think I needed to take them (31%)
• Painful or frightening side effects (28%)
• Drugs prevented me from doing other things I wanted to do (25%)
• No one reminded me to keep taking or refill (20%)
• Difficulty getting prescription filled (20%)
• Unpleasant taste or smell (19%)
• Difficulty opening the bottle or swallowing the drug (16%)
• Confused by all the drugs I had to take (15%)

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Informedix and McKesson Bioservices are testing the Med-eMonitor, which reminds patients to take their medicine, and can be programmed to ask for patient-specific information. The device communicates automatically with a web server.

According to CIO Insight:

The device is about the size of a videocassette and can be carried in a fanny pack. Multiple drawers each hold about a month’s supply of medicine. It alerts the patients when to take medicine, records the date and time when a medicine drawer is opened, and prompts patients to answer questions and complete other tasks.

The CEO of Informedix, Bruce Kehr says he thought up the Med-eMonitor after seeing his elderly grandmother struggle to manage her multiple drug therapy. Doctors often don’t know what to do when they see patients who aren’t responding to treatment –are the medications not working or are patients just not taking them as directed?

The device is being used now in a schizophrenia trial, where it is helping patients remember to take their schizophrenia medications. This has a big impact on the patients’ ability to function.

The Med-eMonitor and once a month osteoporosis pill (Boniva) I posted about on Monday are contrasting approaches to the challenges of adherence and compliance. The Med-eMonitor attempts to manage complex regimens, while Boniva attempts to reduce the complexity.

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There’s another article on emergency room overcrowding and quality problems, this time in the Wall Street Journal (Is it a Heart Attack –or Indigestion? Helping the ER Doctors Get it Right). As we’ve read elsewhere, ERs are getting more crowded, triage is difficult, and information sharing and analysis isn’t as good as it should be.

The article focuses on what patients can do to improve the chance of a correct heart attack diagnosis, such as volunteering information on their risk factors, medical and family history, and carrying a copy of a previous ECG in their wallet. In an unconnected, paper-based system, that’s the best we can do. But there are clear limitations –starting with the fact that it’s hard to recall the key information when you are having a heart attack (or are unconscious).

A better solution is a communitywide electronic infrastructure –such as those being piloted by the Massachusetts eHealth Collaborative that I posted on yesterday– which would allow the ER to quickly retrieve all the information mentioned above and more. Such a system would improve the accuracy and comprehensiveness of the information, and reduce the amount of time required to gather it. And that’s just the start. A truly connected, coordinated care system would reduce the number of cases that end up in the emergency room by enabling earlier diagnosis and prevention before a crisis strikes.

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The Massachusetts eHealth Collaborative (MAeHC) announced that it has selected Greater Brockton, Greater Newburyport, and Northern Berkshire to participate in a 2-3 year demonstration project to test the effectiveness and practicality of implementing electronic health records (EHRs) on a communitywide basis. The communities were chosen from a field of 35 applicants, which was narrowed to six finalists last month.

The ambitious program is backed by a $50 million funding commitment from Blue Cross Blue Shield of Massachusetts. The collaborative has 34 member organizations, including physicians’ and nurses’ groups, hospitals, health plans, the state government, provider and technology associations, and business, purchaser and public interest groups.

The Collaborative’s CEO, Micky Tripathi was hired from the Boston Consulting Group (BCG), where he and I were colleagues. While at BCG, Micky was on loan to the Indiana Health Information Exchange where he led the launch of a similar community-wide effort in Indianapolis.

Community-based initiatives are a good way to go:

• With strong local leadership, a community can bring together disparate providers into a real care system, enabling patients to benefit from coordinated care
• Having an intensive, local effort enables participants to gain critical mass and thereby enjoy benefits faster than in a less intensive rollout over a broader geographic area (e.g., statewide)
• Once communities are wired up individually, it will be reasonably straightforward to link them into a wider network

It’s extremely encouraging that the Collaborative received strong applications from so many communities. The downside is that with only three winners there will be a lot of disappointed communities that won’t want to wait until the demonstration projects are done. The Collaborative will try to help other communities, but it may be stretched too thin.

Implementing EHRs across the whole state could cost $1 billion, according to the Collaborative. In the near term, it might make more sense for communities that haven’t been selected to take initial steps that fall short of a full-blown EHR. Enabling electronic prescribing, online communication of lab results, and doctor/patient messaging are relatively low cost, high impact examples that can begin to connect a community to itself.

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Boniva, a once a month pill for osteoporosis, has won Food and Drug Administration approval, according to the Wall Street Journal. Existing products must be taken at least weekly.

Introducing more convenient dosing is a popular strategy. It provides real benefits to consumers by making it easier to stay on the medication. This is especially true for bisphosphonates such as Boniva and Merck’s Fosamax, because the patient needs to remain upright for 30-60 minutes following administration. It’s also good for drug companies, because it often enables them to extend an existing, proven compound and charge the same amount per patient per year despite selling fewer pills. This is less risky and costly than developing a new compound and helps stave off generic competition.

Boniva breaks new ground by being the first oral treatment for any chronic condition that is taken as infrequently as once a month. Usually, achieving such a dosing interval has required injection. In fact, Novartis is working on a once a year injection for osteoporosis.

Roche Holding developed the drug and it will be marketed by GlaxoSmithKline.

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Prostate cancer is more common and has a higher mortality rate than breast cancer, but relatively little money is spent on it and not much is understood about its causes, according to an Associated Press story in the Boston Globe.

”The prostate cancer community is 10 years behind the breast groups in terms of being acknowledged and coming forward,” according to Dr. Ernie Brodie, a surgeon who got a breast cancer stamp approved that has raised $50 million. Dr. Brodie apparently has prostate cancer, and has become aware of the stark funding and attention gap between breast and prostate cancer.

The breast cancer community is well organized, and prostate is trying to follow that example. The prostrate group recently held a meeting in Orlando, modeled on the annual San Antonio Breast Cancer Symposium, which has been held for 27 years.

As I wrote last week, strong patient advocacy can be the most powerful force in driving innovation in biomedical research. HIV and breast cancer are the best examples. So compared with those, how well suited is prostate cancer as a cause to rally around?

On the plus side:

• It tends to strike late middle aged or older men, who have the ability to give money for research or allocate corporate resources. The most notable example is Michael Milken’s Prostate Cancer Foundation

On the negative side

• It doesn’t usually strike young people in the prime of life, like breast cancer or HIV
• Widespread PSA testing isn’t necessarily a good idea –it leads to false positives and inconclusive results, which lead to damage from misdiagnosis and unneeded treatments. Even when there clearly is disease, it doesn’t always make sense to treat aggressively
• The behavioral and genetic risk factors aren’t clear cut. Better diet, stopping smoking, and losing weight may all help –but that’s the same advice as for other conditions such as hypertension
• Older men are less apt to rally around a cause (or wear a ribbon) than other groups

So overall I don’t expect prostate cancer awareness and advocacy to be the next big thing.

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The Rhode Island medical examiner’s office will be subject to a customer satisfaction survey in the coming months, according to an Associated Press story in the Boston Globe. The agency has been criticized for its handling of the Station nightclub fire, organ donations, and turnaround time in completing autopsies. (Some take 6 months or more!)

The New England Organ Bank has complained that “dozens of potential donations” could not be harvested due to problems with the office’s processes. That’s bad news for patients, considering the severe shortage of organs for transplantation.

David Gifford, acting director of the Health Department, plans to…

…streamline operations by revamping the office’s information technology. An upgraded system is expected to free staffers from hours of pen-and-pad documentation and allow them to more quickly analyze data.

Maybe they can throw out the fax machines while they are at it.

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The Fax Machine: Technology That Refuses to Die, in today’s New York Times, reports that “the fax persists as a mockery of the much-predicted paperless society.” Sales of fax machines are rising.

The main businesses I encounter that still rely on faxing are doctors’ offices and pharmacies, and sure enough there was a mention of this in the article. The author and a CVS spokesman put this use in a positive light, touting the benefits of faxed prescriptions compared with telephoned or hand-carried prescriptions. Faxes provide a written record and reduce security issues associated with email, they say.

Think about these claims in relation to the financial services or airline industries and you will realize how far behind the times medicine is. Remember when you had to write out withdrawal slips by hand and wait in line for a bank teller? ATMs have been in place since the 1970s –with security and documentation controls that are more stringent than for pharmaceutical dispensing. Remember when your travel agent used to write out airline tickets using red carbon paper? Those days are long gone.

Even physicians who use “electronic” prescribing often print out the prescription and fax it in or hand it to the patient, eliminating most of the benefit. Change is under way, led by governmental and private payer e-prescribing programs, and enabling initiatives such as Rx Hub, but it’s slow going.

In the meantime, maybe we should consider a tax on faxed prescriptions to discourage their use and to speed adoption of 20th (or even 21st) century technologies.

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