Health Business Blog

More than a year ago Mickey and I blogged about the breach of privacy during President Clinton’s hospital stay (Enquiring minds want to know). High-profile privacy violations are in the news again.

Take the case of Britney Spears:

UCLA Medical Center is taking steps to fire at least 13 employees and has suspended at least six others for snooping in the confidential medical records of pop star Britney Spears during her recent hospitalization in its psychiatric unit, a person familiar with the matter said Friday.

In addition, six physicians face discipline for peeking at her computerized records, the person said.

Questioned about the breaches, officials acknowledged that it was not the first time UCLA had disciplined workers for looking at Spears’ records. Several were caught prying into records after Spears gave birth to her first son, Sean Preston, in September 2005 at Santa Monica-UCLA Medical Center and Orthopaedic Hospital, officials said. Some were fired.

and also George Clooney:

Just weeks after George Clooney was injured in a motorcycle accident and taken to Palisades Medical Center, CBS 2 HD has exclusively learned that dozens of employees, including doctors and nurses, have been suspended for accessing Clooney’s confidential information.

The 46-year-old actor suffered a broken rib and road rash while a companion riding with him suffered a broken foot in the collision with another vehicle.

Within minutes, the media seemed to know everything about Clooney’s condition, and sources tell CBS 2 HD that hospital officials are now investigating whether or not their own employees leaked information about Clooney to the media.

Such episodes are especially damaging because they constitute the public’s knowledge of the state of medical privacy with EHRs and thereby undermine support for digital records. There needs to be:

• Real-time approval for flagged VIP cases
• Prior approval for relevant hospital personnel in VIP cases
• Dismissals of the violators

Clooney said:

[W]hile I very much believe in a patient’s right to privacy, I would hope that this could be settled without suspending medical workers.

It’s nice of Clooney to be so magnanimous, but I disagree with his statement. When celebrities enter the hospital there’s an opportunity to benefit public health. The classic example is how Betty Ford’s treatment for alcoholism opened up national discussion on that issue. Let’s hear about how a celebrity’s life was saved by CPOE, decision support or some other electronic tool, rather than confirming our worst fears about electronic privacy. And let’s see to it that violators are dealt with in a serious way.

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Change of Shift, the nursing blog carnival, is up at Emergiblog.

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From the New York Times (Cutting Dosage of Costly Drug Spurs a Debate)

When a drug can cost more than $300,000 a year, the right dose becomes a matter of public debate.

The drug in question, Cerezyme, is used to treat a rare inherited enzyme deficiency called Gaucher disease. Some experts say that for most patients, as little as one-fourth the standard top dose would work, saving the health care system more than $200,000 a year per Gaucher patient.

“It is economic malpractice to give a much higher dose of an expensive drug than is required,” said Dr. Ernest Beutler, an authority on Gaucher disease at the Scripps Research Institute.

Some other Gaucher specialists argue otherwise, saying that skimping on the medicine could endanger patients.

The economic stakes are high, but a big part of the problem is how drugs are priced in the first place. Infused and injected drugs (which are also usually the most costly) tend to be priced by volume or vial. Use twice the dose of Cerezyme and it will cost twice as much.

Interestingly this is not the pricing model generally used for pills. Higher strengths of drugs like Lipitor don’t tend to cost much more than the lower strengths, if they cost more at all. That’s the reason that pill splitting is used to cut costs.

I’d like to see someone try pricing drugs like software. After all, it costs very little to manufacture software or drugs. Most of the cost is in R&D. Therefore a licensing model could work well. Rather than charging a Gaucher patient twice as much if they use twice the dose, why not just charge by patient-month or patient-year? Same thing with less expensive pills like Lipitor for chronic conditions. Charge a certain amount per patient-year and let the patient and doctor adjust the dosage to the right level.

Shifting to a licensing model would require some changes. For example:

• Shifting from prescription-by-prescription co-pays to a monthly or annual license. This probably wouldn’t be so hard, and existing PBMs could handle it
• Putting in place safeguards to protect against product diversion. This wouldn’t be a big deal if everyone went to a licensed model, but of course that won’t happen. In a mixed system patients with drug licenses might sell or give surplus drugs to others. This would need to be addressed, although arguably such diversion doesn’t have to be cut to zero to make licensing worthwhile

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Polite Dissent hosts the latest Grand Rounds.

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This is a guest post by freelancer Susan Jacobs.

New Jersey officials announced yesterday that they would like to have everyone in the state insured with medical coverage by the year 2011. The Associated Press reports that 1.4 million New Jersey residents are currently without medical insurance. 275,000 of the uninsured are children, which is one of the state’s biggest concerns.

This new plan would first focus on children and parents, as well as health care reforms that would benefit small employers and individuals. Next, a state-sponsored program would be implemented to offer aid to those who can’t afford coverage. Those behind this ambitious project are already recognizing problems with the plan, however.

Approximately 76 percent of all insured residents are covered by their employer. Once this new statewide health care plan takes effect, nothing will stop some employers from dropping their employee’s health benefits. States are prohibited from forcing employers to cover their workers, after all.

Senator Joseph Vitale addressed the potential problem of employers dropping their workers’ coverage. His prediction, however, is one of optimism. He feels that most employers will keep covering their workers in order to keep their employees happy.

On this new health care plan, Vitale also states, “This is an idea whose time has come as more New Jersey families are struggling with the high cost of health care and more state residents than ever before worry that they may be one serious illness away from bankruptcy.”

Will New Jersey’s budget support a successful universal health care plan? This remains to be seen, though this isn’t the only state jumping on board with such a plan. Both Maine and Vermont are also working on universal health care plans.

Susan Jacobs is a part-time teacher and a regular contributor for NOEDb, a site for learning about and selecting an online nursing degree program. Susan invites your comments and freelancing job inquiries via email.

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I’ve been back from Uganda for a few days but am still taking Malarone to prevent malaria. I’ve experienced some mild side effects that I attribute to Malarone, including minor dizziness and slight stomach upset.

I woke up around 3 am today with the uncomfortable realization that I’d just had an unusual dream in which I killed 5 or 6 people. Although I sometimes have strange dreams, this one struck me as especially odd.

Although I can’t say with certainty, I’m guessing the dream was sparked by the Malarone. Side effects of Malarone seem to be less frequent and less severe than for its competitor Lariam, but “strange, vivid dreams” is still a relatively frequent side effect, according to the GSK website.
I’m taking a fairly low prophylactic dose, which should keep the side effects at bay. If I were taking a higher dose of Malarone for full-blown malaria just imagine the magnitude of the nighttime slayfest!

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Two Congressional Reps have introduced a bill to create a pathway for generic biopharmaceuticals. It seems to me like a big waste of time.

The bill has the following key provisions, according to Kaiser Daily Health Policy Report:

• 12-14.5 years of market exclusivity for the original product before generics can appear
• Clinical trial requirements for follow-on products, which could be waived by FDA (I don’t have more details on this yet)
• Exempting “select agents and toxins” like Botox from competition, for “national security” reasons. (Maybe it will keep the enemy wrinkly-faced?)
• Granting the FDA the authority to declare medications as interchangeable

I can’t imagine how this bill would have any significant impact on drug costs. It seems likely to severely limit the number of biotech drugs facing serious competition, which will keep prices up. The only beneficiaries will be brand name biotech companies and a few generic biotech companies who get drugs approved and enter into an oligopolistic market environment.

As I’ve said before, a better idea would be to simply regulate the prices of biotech drugs once they’re off patent (or have been on the market for a certain number of years). Advantages of this approach include:

• Guaranteed, predictable savings
• Elimination of risky and expensive clinical trials of follow-on products, with their potential to harm patients
• Limitation on the breadth of FDA oversight. Fewer new manufacturing facilities makes it easier for FDA to keep up
• Higher manufacturing capacity utilization for brand name companies, who will retain 100 percent of the market

The only losers will be generic biotech companies. Since that industry doesn’t really exist yet, I don’t think it’s such a problem.

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Kevin, MD called my attention to a USA Today op-ed he authored on the root cause of trouble in the US health care system: the shortage of primary care. I agree with Kevin that this is a serious issue. I know it’s a big problem in Boston.

But just to put things in perspective, at the meeting I’ve been attending in Kampala, Uganda I learned from a health ministry official from one African country that fewer than half the clinics in his country have a midwife, never mind a physician or nurse practitioner, and that many lack electricity or access to clean water. In Uganda there are 8 urologists for a population of about 25 million.

There used to be more health care workers available, but many have moved abroad to greener pastures.

It’s worth at least noting the impact overseas of the US’s reliance on imported physicians, nurses, etc.

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Check out the latest version of the Cavalcade of Risk at Regulating Health Insurance.

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I’m in Kampala, Uganda for a two-day meeting on male circumcision for HIV prevention, organized by the Forum for Collaborative HIV Research and the Bill and Melinda Gates Foundation. There are people here from all over Africa and the rest of the world to discuss the topic. Circumcision is a hot subject right now, after 3 randomized controlled studies showed that it reduced female to male transmission by about 50 percent.

It was a long trip over here: Boston to Chicago, Chicago to Brussels, Brussels to Bujumbura (that’s the capital of Burundi in case you were wondering) and then on to Entebbe, the international airport outside of Uganda’s capital, Kampala, which is mostly known as the site of a daring rescue by the Israel Defense Forces in 1976. Shockingly everything on my trip went smoothly and 30 hours after leaving my house I was at my hotel.

My preparation for the trip began a few weeks ago. Although my primary care physician didn’t think I needed to take any precautions, I decided to second guess him and visit the BIDMC’s travel clinic, where I was persuaded to get the Yellow Fever vaccine, typhoid vaccine and to take malaria prophylaxis. I think it was the right thing to do.

I had read on Uganda’s website that a visa could be obtained upon arrival at Entebbe, but I had a scare late last week when I was told by conference organizers that a visa had to be obtained ahead of time. It was too late to send my passport away, so I called the Uganda embassy in Washington, which told me that it was “advisable” to get the visa beforehand because I might be denied boarding by my airline otherwise. I then called American Airlines and was assured that all would be ok. Still, I was nervous because I was transferring to Brussels Airlines once I got to Europe. Thankfully there was no problem and I obtained my visa upon arrival, just like several other people. It didn’t even take any extra time.

When we landed in Bujumbura it was almost completely dark all around. It’s pretty shocking compared to landing in a US, European or Asian destination. I saw a mosquito on the plane, buzzing around my seat. I really don’t want to get malaria so I put on some DEET that I brought along.

When we landed at Entebbe there were plenty of bugs flying around between the plane and the terminal and in the terminal itself. I met up with a couple of other people attending the conference and a driver took us to our hotel, about 40 minutes away. Apparently that road is choked up during regular hours. Luckily it was about midnight when we arrived.

The Kampla Serena Hotel where I’m staying is first rate. Only problem is that they were overbooked. Somehow I got a room and my two companions were shunted off to a nearby, lower class place. Actually, I’m quite sure there was at least one more room available, and that the manager was lying to us. That’s because he first tried to get the other man in our group and me to share a room, saying there were two double beds. However, my room has a king bed. I really wonder whether this hotel wants to upset the Gates Foundation. It may not be a wise move.

Anyway, my room is very modern except that it lacks a clock. Otherwise it has all the amenities including A/C, two desks, wireless and wired Internet access, fancy bathroom, balcony, etc. In the bathroom there is a can of insect killer. First I sprayed it into the air over my bed, then a few minutes later I saw a mosquito in the bathroom and blasted it out of the sky with the same spray. (I had to hit him twice.)

By the time I got to bed it was about 2 am local time, and I had to get up a few hours later. Fortunately, I feel pretty good today and don’t think any mosquitoes bit me while I was asleep.

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