Health Business Blog

Boston Globe sides with the sippers

I’m voting “No” on Massachusetts ballot question 1, which would permit the sale of wine in more food stores, because I think it would increase underage drinking and associated problems. Unfortunately, the Boston Globe sees things differently and has advocated a “Yes” vote:

[T]he availability of wine with groceries does make life a little more convenient for the many adults who like to sip wine with their dinner…

Ok, as long as it’s just sipping wine then I guess it’s ok. But I’m more worried about the chuggers and those who skip dinner entirely!

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Hooray for hospitalists

Hospitalists, physicians who practice internal medicine solely within the inpatient setting, are profiled in today’s Boston Globe. One of the weirder things about hospitals is there usually aren’t many doctors around. Primary care physicians tend to round in the early hours of the day, and then patients are left with nursing and administrative staff the rest of the time. Hospitalists address that deficiency by actually being in the hospital most of the day.

The article profiles Dr. Faisal Hamada, who runs the hospitalist program at Brockton’s Caritas Good Samaritan Medical Center. He’s actually employed by Cogent Healthcare, an Irvine, CA –not Philadelphia as the article states– based provider of turnkey hospitalist programs. Cogent provides the hospitalists, support staff, protocols and IT systems. The company generates a return on investment for its clients by improving the quality and efficiency of the hospital. Because hospitalists are around they can make adjustments in a patient’s schedule during the course of a day, something a primary care is unlikely to do after rounds . That kind of intervention tends to improve length of stay.

Good hospitalists develop a rapport with community physicians, which is essential so that those physicians don’t feel like the hospitalists are stealing their patients. I’m not surprised that Dr. Hamada is complimentary to the community physicians, but it’s also a fact that hospitalists tend to be more competent working in the hospital than their community-based colleagues. Hospitalized patients tend to be very sick –sicker than office-based physicians are used to seeing. Hospitals also have their policies, procedures, and informal ways of getting things done. It’s easier for a hospitalist to be good at this part of the job than someone who is only in the hospital occasionally.

One of the common complaints about hospitalists, also echoed in this article, is that there is a gap in communication between the hospitalist and the primary care physician, so that patients can get in trouble in between the time they are discharged and the time they see their community doc again. But that actually shouldn’t be such a problem in Brockton. Unlike most hospitalist programs, Cogent has its own call center to follow up with discharged patients, and has specific protocols for communicating with community physicians. In addition, Brockton is one of the three Massachusetts communities that is being wired up with a health information exchange as part of the Massachusetts eHealth Collaborative. That should make it much more straightforward for hospital-based and community-based physicians to stay in touch. Patients will benefit.

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I’m voting “No” on Massachusetts ballot Question 1

In Massachusetts, alcohol is sold at liquor stores (called “package stores” here) and at a limited number of grocery stores. Most other states have more liberal rules than we do about where alcohol can be sold. It’s the norm in the US to have alcohol sales in supermarkets.

Question 1 on the Massachusetts ballot asks voters whether to expand the number of licenses that can be issued to grocery stores to sell wine. Predictably, grocery stores support the measure while package stores oppose it. There’s nothing principled about their arguments, but that doesn’t mean that there isn’t merit to some of what they say.

Supporters, led by Grocery Stores and Consumers for Fair Competition argue that a Yes vote will reduce prices and provide consumers with more choice. They cite the experience of other states.

Opponents, led by Wine Merchants and Concerned Citizens SAFETY (Stopping Alcohol’s Further Expansion to Youth) argue that a Yes would make it easier for kids to buy alcohol, which would increase the number of alcohol related problems such as drunk driving fatalities. This is especially likely because there is no provision to increase resources for enforcement of minimum age laws.

I agree with the wine merchants more than the grocers. I don’t believe that Massachusetts will do a good job of keeping grocery stores from selling to underage buyers. I don’t doubt that the owners of the stores will try to avoid selling to kids, but when a large part of the checkout staff are themselves underage I think it will be hard to stop.

A better idea might be to hold the package stores to a higher standard, putting them at greater risk of license forfeiture for underage selling.

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Let’s hope BMS can keep Hummingbird’s wings flapping!

One thing almost everyone in Massachusetts seems happy about is Bristol-Myers Squibb’s plan to build a biotech manufacturing facility on the site of the old Fort Devens. In last night’s gubernatorial debate, Democrat Deval Patrick praised Republican Kerry Healey for her role in making it happen. There was even more exuberance when the deal was announced:

“We’re walking on air,” said Thomas Finneran, president of the Massachusetts Biotechnology Council, among the many industry and state groups that worked to lure Bristol-Myers. “It was very impressive. For us to beat North Carolina in this type of competition is almost like a Nixon-to-China type of breakthrough. Nobody would have expected it.”

Governor Mitt Romney praised the announcement as evidence of his administration’s ability to nurture high technology in the state. The legislature approved tens of millions of dollars in infrastructure improvement for the site and the BMS facility is the return on that investment.

The facility is supposed to break ground around now and begin production by late 2011. BMS expects to hire about 550 people and spend around $600 million.

It sounds wonderful and I hope everything comes to pass as planned, but I’m starting to get a little worried. Consider:

• BMS still hopes that its one biotech drug, Orencia, will be a billion dollar product. But considering it’s a late entry in the rheumatoid arthritis arena and that the drug requires a 30-minute intravenous infusion rather than subcutaneous self-injection like competing products, I’d say it’s doubtful. Sales were only $34 million in Q3 2006.
• It’s far from certain that BMS will have additional biotech products in the near term. It’s impressive that they were able to develop and launch Orencia, but that doesn’t mean they’ll be able to do it again. If Orencia sales are lower than expected and there aren’t other products, do they really need to build a whole new facility?
• BMS is not in a strong financial position overall. Probably one reason they decided to build the new facility in the continental US rather than in a tax haven like Puerto Rico is that they need to generate cash onshore to fund the dividend. That’s doubly true in the wake of the Plavix fiasco, which sent BMS’s 3rd quarter profits down to $338 million from $964 million a year earlier. If BMS is acquired how secure is the commitment to Massachusetts?

I don’t doubt BMS’s sincerity, I just hope they have the wherewithal to pull off their original plan. Meanwhile, I wonder what kind of recourse Massachusetts would have, if any, if BMS has to walk away.

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Another dirty little secret is out in the open

A year ago in Time to deal with medicine’s dirty little secrets?, I wrote about a variety of practices that are relatively well-known in the health care field but would be shocking to outsiders. Industry often takes the blame for “aggressive marketing tactics,” and no doubt some of that is deserved. But physicians are also culpable.

The open secrets include the ghostwriting of journal articles by industry sponsors, physicians and academic medical centers holding ownership stakes in companies whose products they are researching, the clinical role sometimes played by orthopedic sales reps, and perhaps the most egregious example: physicians who set guidelines having financial relationships with the companies that benefit from how those guidelines are set.

Now we have a new example, which is even more serious than usual. A recent New England Journal of Medicine article blames Eli Lilly for overzealous promotion of Xigris. According to the Boston Globe:

Eli Lilly and Co. funded medical guidelines created for the treatment of [sepsis] in an effort to boost sales of a drug with questionable benefits. The allegation was made by senior scientists at the National Institutes of Health. [They] said Lilly tried to shape the guidelines for use of the drug Xigris by sponsoring a three-pronged marketing campaign

The first two phases are by now almost standard practice in the industry:

1. Lilly paid a task force to spread the word that hospitals were rationing Xigris because of its cost, which forced docs “to decide who would live and who would die”
2. Lilly “orchestrated” the development of practice guidelines to treat sepsis that called for early use of Xigris (an example of the phenomenon I have described before)

But then Lilly allegedly took a third step, which was a little shocking even to me:

Now, Lilly is sponsoring lobbying efforts to turn the guidelines into quality standards. Hospitals that follow such quality measures receive higher payment from insurers.

What’s happening here? Basically, an influential group of doctors is being lazy and greedy, and Lilly is enabling their behavior. The doctors put their fingers in the cookie jar and Lilly keeps restocking it. The public is paying for the cookies –in the form of higher product sales and sub-optimal health care– and should get fed up!

I have no problem with companies using legal means to promote their products, even if their tactics are “aggressive.” They owe it to their shareholders to maximize return on investment. But it isn’t in their long-term interest to push things as far as the medical profession often lets them.

Industry leans on the reputations of individual physicians (aka “key opinion leaders”), medical societies (aka guideline writers), and journals to legitimize their marketing messages. It’s up to the medical profession to scrutinize industry claims and issue independent guidelines and quality standards. Sometimes these claims hold up and deserve to be propagated. Sometimes they don’t. If the docs and journals don’t do their jobs they deserve to lose credibility.

It’s hard to know the extent to which medical guidelines are already corrupted. The situation is a bit like the incident when the Chinese President’s plane was refitted. In the process of fixing up the plane someone inserted a bunch of listening devices (presumably at no extra charge). When the Chinese checked out the plane and realized it was bugged they had to rip the whole thing up. That’s something like what is going on within the major payers. They’ve stopped treating journal articles and guidelines as objective and have started doing their own analyses. But do we really want to leave health care decisions just to them?

Here’s some free advice to the different players in health care:

• Industry: Feel free to market your products and services aggressively, but don’t take things too far. If you do you’ll end up killing the goose that lays the golden eggs. No one will trust doctors, guidelines or journals anymore
• Physicians: Remember that pharma and device companies are not stupid. If they spend money supporting your research or sending you to conferences or sponsoring continuing medical education it’s because they expect to get a return on their investment. It’s awfully hard to remain objective in such instances. Your job is to adopt the best medical practices and put the patient first –sometimes that requires expensive new treatments and sometimes old, cheap standbys are better
• Payers: Go ahead and challenge the objectivity of journal articles and guidelines. On the other hand, don’t pretend that low cost is always synonymous with best treatment. Expect physicians to keep you in line on that.
• Patients: You need to look out for yourself. Find a good, honest physician. Take a look at who’s sponsoring the educational materials you receive. Ask your physician about alternative treatments and do some research yourself

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A good way to avoid travel illness, but you better hurry

I tried out Eurofly today, which has an all business class service between Milan and JFK. There are only 48 seats on the Airbus 319, and more remarkably only 6 were full (including mine)! I knew something was up when they seemed to recognize my name when I checked in.

Unlike on most flights I was not really worried about catching the flu from a fellow passenger. On the other hand with a 12.5 percent load factor this route may not last long.

However, there are a couple of downsides you might want to consider before boarding: a flight attendant who seemed to be sneaking cigarettes in the galley (stinking up the plane) and an electrical power system that didn’t work. Luckily I brought along two laptop batteries.

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Will barf bag ads save Alitalia?

Flew the overnight flight from Boston to Milan on Alitalia. The plane was less than half full and I understand the company is essentially insolvent.

But they seem to have a source of incremental revenue: advertising motion sickness pills on the barf bags (in Italian only). I’m not sure barf bag users appreciate reading an ad that essentially says, “I told you so.”

Alitalia may need to find some other source of salvation.

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A head lice policy that isn’t a nuisance

As I’ve written before (George Bush: Louse Enabler?), schools tend to go overboard on their head lice policies, enforcing strict “no nit” rules that don’t make a lot of sense. So I was happy when I found the following announcement from a local school. It seems like a very sane way to go: