Health Business Blog

American Imaging Management (AIM), a radiology cost containment company owned by health insurer WellPoint, has a web-based patient exposure tool called Aimee that provides information for doctors and patients about the amount of radiation associated with various scans.

The site is well-designed and easy to use. Simply click on the relevant scan and portion of the anatomy and the site provides a summary of the purpose of the exam and suggests safer alternatives when appropriate. At the bottom of the page is a display that expresses the radiation exposure in millisieverts (mSv) and as its equivalent in chest x-rays and background exposure. I like the site because it raises awareness about radiation exposure and provides alternative recommendations patients could discuss with their physicians.
According to AuntMinnie, a radiology news and information site, some physicians are less sanguine. See Criticism aimed at radiation-estimate Web site. Among the complaints:

1. Ownership of the site by a party that has a stake in reducing imaging costs
2. The site’s oversimplification, e.g., not specifying that radiation exposure depends on equipment and protocol, not just the type of scan category
3. The inappropriateness of making comparisons with chest x-rays (e.g., for scans that target other parts of the body) and background exposure (because the exposure comes over time rather than all at once)
4. Lack of relevance for pediatric patients, who will get lower exposures
5. Lack of discussion of the benefits of imaging

Some of these criticisms are reasonable and I hope AIM takes them into account as it updates Aimee. Still, I don’t think they’re completely fair:

1. Ownership: As long as AIM’s information is objective, I don’t think it matters who owns the site.
2. Oversimplification: I’m sure there are improvements that can be made, but I don’t know if that would really make the information more useful. Perhaps just indicating that there is a range would be enough. This criticism sounded more like an objection to having the information posted at all.
3. Appropriateness of comparisons: Since most people don’t understand mSv, the other comparisons are at least somewhat helpful. And it’s not as dramatic as comparing the exposure to the level of radiation received by atomic bomb survivors, which I’ve also seen!
4. Pediatric: This is an important consideration. On the other hand, as the Image Gently folks have described, pediatricians and radiologists have plenty of room for improvement on radiation exposure practices. Casting stones at Aimee won’t really help.
5. Lack of discussion of benefits: Imaging is a large, rapidly growing contributor to medical spending. There’s no particular need for Aimee to talk about imaging’s benefits.

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I spoke today with Rich Noffsinger, CEO of SafeMed, a clinical decision support company based in San Diego. I first met SafeMed’s founder, Dr. Ahmed Ghouri, a couple of years ago when the company was starting a pilot at Beth Israel Deaconess Medical Center in Boston. I liked the demo I saw then and have been following the company ever since.

In our interview, Noffsinger brought me up to speed on SafeMed’s collaboration with Google, progress in radiology, and the impact of SafeMed on costs, quality and patient safety.

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Interview with SafeMed CEO, Rich Noffsinger Play Now | Play in Popup | Download

The Health Business Blog has been listed as one of the “25 Best Health Blogs,” by Fathom SEO.

Fathom’s Paul Richlovsky chose the blogs on the basis of subjective criteria:

• frequent, regular posting (daily/near-daily)
• quality design (readable, pleasing to the eye, no overwhelming advertising/clutter)
• a distinct viewpoint
• depth and breadth of health commentary

The publication includes a short paragraph on each blog that is quite useful. You can read Paul’s post on the topic and view his vodcast.

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Check out the latest edition of the Cavalcade of Risk at Worker’s Comp Insider.

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Dr. Val hosts the latest edition of Grand Rounds.

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In August, Questcor Pharmaceuticals announced “a new strategy and business model for H.P. Acthar Gel(R). Later that month you may have read my post (Abusing the orphan drug law to rip off customers), which explained how the company obtained orphan drug status for a product that had already been used for decades for Infantile Spasms (the orphan indication) and raised the price from $1600 to $23,000 per vial.

There’s a lot to explore in this story, and other bloggers have probed the issues more extensively than I have. (See the comments section of the original post for some of them.) For example: is it reasonable to use orphan status –designed to encourage development of new products– to boost the profitability of older products and potentially keep new products off the market? What are the alternative treatments for Infantile Spasms? How well do patient assistance and other price discrimination programs work in practice? How does Questcor’s inconclusive clinical trial for Infantile Spasms figure in?

The New York Times was working on a story about this topic during the fall. I know because I spent quite a bit of time educating a reporter about Questcor and H.P. Acthar. For whatever reason, the story never ran. That’s how it goes sometimes. (It wasn’t among all the news that was fit to print, I guess.)

So I was surprised to see the story in Saturday’s New York Times (Benefit Managers Profit by Specialty Drug Rights) and disappointed that the writer (a different one than I spoke with) ignored the Questcor and orphan drug law issues and focused instead on the distribution of specialty pharmaceutical products by pharmaceutical benefits managers. Here’s how the Times handled it:

As it turned out, the exclusive distributor of H.P. Acthar Gel is Express Scripts, a company whose core business is supposed to be helping employers manage their drug insurance programs and get medicines at the best available prices.

But in recent years, drug benefit managers like Express Scripts have built lucrative side businesses seemingly at odds with that best-price mission. A growing portion of their revenue comes from acting as exclusive or semi-exclusive distributors of expensive specialty drugs that can cost thousands of dollars. And the prices of such medicines are rising much faster than for the mainstream prescription drugs available through a wide variety of distributors…

“We are headed right down into conflict alley with these exclusive arrangements,” said Gerry Purcell, an Atlanta-based health benefits consultant to big employers. As exclusive or semi-exclusive distributors of specialty drugs, the benefit managers “can raise the prices at will,” Mr. Purcell said, “and the employer will have little chance but to pay the bill.”

The Times implies that Express Scripts is responsible for the price increase, and that the exclusive distribution arrangement drives prices up. It’s an odd way to focus the article.

It’s typical for specialty drugs to have a sole distributor and such arrangements have almost nothing to do with why specialty drugs are so expensive. Even if H.P. Acthar Gel were distributed widely it wouldn’t mean customers would pay less. The pricing power in this case is at the level of the manufacturer, not the distributor. (As an analogy, think of Microsoft Office. It’s available from many distributors, and prices do vary somewhat. However, Microsoft controls the wholesale price and can boost it or cut it at will. Distributors have little power.)

There are alternative treatments to H.P. Acthar Gel, including steroids and the ketogenic diet. Specialty distributors and PBMs who are locked out of the Questcor account have an incentive to promote such alternatives, which could be to the benefit of their customers and themselves.

In Questcor’s initial press release the company mentioned a number of risks inherent in the price boost, including the possibility that insurers would resist the price increase and that negative publicity would cause problems for the company. Neither of those things seems to have happened to any great degree, and the delayed, New York Times article, which points the finger in the wrong direction, is part of the reason.

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Three Singapore hospitals have been added to Companion Global Healthcare’s international medical travel network. HealthLeaders has an initial story on the topic, and I’m quoted in it.

I visited two of the three hospitals: Mt. Elizabeth and Gleneagles, and they are first rate. To read my impressions of them see the profile on MedTripInfo and listen to the podcast interview I did with Parkway’s COO, Dan Snyder.

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If you missed the live chat on Peyronie’s Disease (PD) on April 16, a transcript has been posted. This is an excellent example of when to use the live chat format. The topic is sensitive and embarrassing, which impairs the flow of high quality information through the usual channels. As a result, there is high interest in gaining anonymous access to information, which chat provides.

A few things I learned from reading the transcript:

• There is a lot of misinformation about PD; a number of ineffective or even harmful treatments are being used
• Some patients are being told by physicians that there’s nothing that can be done for the condition, which is untrue
• PD cases have been associated with various treatments for prostate cancer
• Auxilium Pharmaceuticals is conducting a clinical trial for a PD treatment

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American Public Media, which produces radio shows such as Marketplace, has launched Health Care Idea Generator, a website dedicated to a discussion of how to improve the American health care system. Everyone seems to have an idea or two on what’s wrong with health care and how to fix it, so the site is an attempt to harness that energy.

The site is well designed, and the initial tour provides an easy-to-understand introduction to its various features. There are tabs to represent the perspectives of various stakeholders including caregivers, insurers, employers, the insured, and uninsured. There’s a nice little lead-in for each to provide the reader with an empathetic view of that constituency, although for some reason they’ve decided to bestow the nickname Pig to the fictional insurance industry representative.

Readers have shared some ideas already. Here are the first few I clicked on randomly:

• Increase face time with doctors: Let doctors decide how much time to spend with patients (rather than be limited to 15 minutes by “insurance” and “business interests”)
• Provide more coverage for prevention
• Provide government support for mental health care of adopted children as they reach adulthood
• Address the nursing shortage by providing more funding for nursing education and paying nurses more

Like so many of the health care ideas out there, all of these will end up boosting overall health care spending, which isn’t going to help our overall problems. I’m sure there are (or will be) other entries that address these aspects as well, but like I’ve said before the free lunch in health care is quite elusive.

One of the clever features of Turbotax is a little “bottom line” indicator that changes every time the user adds an entry.  Add a source of income and the tax owed numbers goes up, accompanied by rolling digits and sound effects, like a slot machine or cash register. Enter a deduction and the same thing happens –but in reverse. It’s a good way to keep track of where things stand.

It’s beyond the scope of the current site, but once a sufficient number of ideas are generated it would be interesting to attach a price tag to each, and then create a simulator that lets users pick and choose their favorite ideas in order to view the outcome along with its impact on costs. A really sophisticated version would look at the impact by constituency and account for interactions among the ideas. An interactive feature like that could really advance the debate.

Since most of the ideas are already out on the table (elsewhere if not yet on the site) maybe the simulator would be a better place to start.

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