Health Business Blog

The Health Business Blog is taking a break this week and is rerunning some favorite posts. If you want to comment, please do so on the original post.

Recently I heard a Rabbi discuss the prohibitions against bribes in Jewish law. He shared the Talmudic insight that “a gift blinds the eyes of the wise” and taught that this refers not just to obvious bribes but even to small, innocent-seeming gestures that appear too insignificant to influence another person but that actually do cause a conflict of interest. I told him this sounded very similar to contemporary relationships between pharmaceutical companies and prescribing physicians, where small gifts like pens and take-out lunches are tools of the trade –viewed as innocuous by their recipients but seen as a good investment by the givers.

I revisited a blog post I wrote on the topic back in 2006 along with aJAMA article (Health industry practices that create conflicts of interest: a policy proposal for academic medical centers) by Brennanet al. from the same era. I looked at the list of articles citing the Brennan piece to see if I could find something more current. Lo and behold I discovered Unconscious conflict of interest: a Jewish perspective by Gold and Applebaum in the Journal of Medical Ethics, which probes this issue in more depth. They write:

To me this is fascinating stuff and suggests that to truly avoid the unconscious conflict of interest in the pharma/physician relationship it would be necessary to cut off all contact between pharma rep and doctor. Even when a drug rep is prohibited from distributing tsotchkes or tapping his restaurant budget, the physician still knows the rep would give him things if he could. Under this logic, the “no see” policies of some physician organizations toward pharma reps make good sense.

There is another solution, which is to educate physicians about unconscious biases and the objectives and tactics of pharma companies, device companies, health plans, and other would-be influencers. Even better would be to couple this education with conscious efforts to counteract any biases that are introduced.

Physicians are notoriously skeptical of the notion that they are influenced by gifts large or small. Therefor the article wisely concludes:

For those disinclined to accept either the insights of sociologists and anthropologists or the findings of modern neuroscience on the tendency towards reciprocity in response to the receipt of gifts and favours, perhaps the wisdom of the ancients provides a reason to rethink the unconscious influence of even small benefits on physician behavior.

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I’ve never been able to work effectively in an open floor plan environment. Quite a few people tout the benefits of communication, collaboration and creativity but it was always obvious to me that productivity in an open plan environment depended a lot on the specific workers involved.

And yet, most discussion of the topic doesn’t take the individual employee into account. Firms debate headphone use at the office from today’s Boston Globe is just the latest example. The topic is whether or not headphones are a good idea in the workplace. The article focuses on productivity, communication between co-workers, and distractions, but there is no emphasis at all given to how preferences might be based on how individuals’ minds work.

I worked in an open environment only once, for less than two years, in my first job out of college. I liked the company but retreated to a conference room or other private space as often as I could. In a later job, where offices were shared, I opted for a small one with no officemate as soon as I could. Ultimately I started my own company and did away with the problem once and for all.

Still, I feel badly for those chained to their cubicles, desks or whatever. It isn’t easy to speak up and ask for a special arrangement, like working from home or in an office. It’s likely to be seen as anti-teamwork. Yet some people can be more collaborative if they aren’t immersed full-time in a common space. Bosses would do well to take the different needs of employees into account when designing workspaces.

Perhaps the introvert bosses among us will take the lead.

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The town center neat my home has a lot to recommend it: restaurants, cafes, book stores, clothing stores, drug stores, food stores, specialty shops and more. But about 7 years ago I noticed a lot of undesirable shops moving in: namely cell phone stores. Every major carrier including Verizon, AT&T, T-Mobile, Sprint –and even some minor players– like Clear has its own storefront. Some are remarkably big. In my view, all of them are pretty useless and detract from the vibrancy of the neighborhood. I’m hoping the day will come soon when the rationale for these stores evaporates and the stores can be put to some other use.

More recently tons of banks have been setting up shop. Also pretty useless from my standpoint –do we really need more than ATMs and the occasional safe deposit box?– but apparently they are grabbing up space as a kind of interactive billboard to fight for share of wallet among an attractive demographic.

I guess I should get used to these blights on the neighborhood because it sounds like something even worse could be on its way: retail stores to sell health insurance. As implementation of the Affordable Care Act proceeds, health insurers are looking for new ways to find retail customers and to bypass brokers. And you guessed it, they’re opening up retail stores to do so. A Kaiser Health News article has more, including a report of a Blue Cross Blue Shield store in Florida, Highmark in Pennsylvania and a 16,000 square foot UnitedHealthcare store in Queens.

So as much as I’d like to see the demise of the phone stores and banks, I really don’t want to see them replaced by the Harvard Pilgrim, Tufts, Fallon, Steward and Blue Cross Blue Shield stores. But I fear that day may be near.

Is this post curmudgeonly enough for you?

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President Obama’s re-election chances are looking better by the day. Conventional wisdom (probably correct in this case) says the economy is the key issue in Presidential elections. If things are going well, the President gets re-elected. If not, then not. Despite the robust efforts of John Boehner, Eric Cantor et al. to talk down the economy or to grind the government to a halt, and despite the European debt crisis, economic growth in the US is looking pretty good.

Meanwhile, the Tea Party’s influence scared off the more reasonable, electable GOP Presidential candidates and we’re left with an odd bunch. Santorum is a pretty extreme social conservative and nowhere near qualified to be president, Gingrich is a narcissist and probably more of a socialist than Obama, Paul appears to be a modern day John Bircher, and who knows where Romney really stands? In any case, the group has taken the primary so far to the right that it’s opened up a huge centrist gap for Obama to fill.

The recent flap over birth control is pretty interesting in that regard. I doubt Obama planned it this way, but it seems likely that things will work out at least neutrally for Obama and possibly very positively. The original Obama proposal, requiring religious institutions to offer birth control coverage — was quite reasonable. It was in line with the policy that’s in place in most states in the US –one that doesn’t generate a lot of debate. When things blew up, Obama back tracked a little bit, forcing insurers to pay for the benefit. His move was enough to at least partially mollify the sincere critics (e.g., Catholic hospitals). But of course nothing Obama proposes will be seen as adequate by his ideological opponents, who are striving to present Obama as trampling on religious freedom.

But opponents are at a serious risk of overplaying their hand. In particular, they may accurately be perceived as against birth control. And that’s not something that the average person in this country is going to be comfortable with.

Birth control is not like the abortion issue. Although “pro-life” campaigners like to portray the “pro-choice” side as “pro-abortion,” it’s just not true. Even those who favor abortion on demand would like to see the number of abortions be as low as possible. That truth is lost on some of the anti-contraception zealots.

As a result of Obama’s partial backtracking, the opposition is split and a bit confused. The real anti-contraception people are coming out of the woodwork, and that’s going to scare the heck out of a lot of undecided and Republican leaning centrist voters. If the Republicans get painted as anti-birth control I don’t see how that’s going to be a winning message for the party. It could even trump bad economic news for some voters.

And although the financial impact hasn’t attracted much coverage, birth control benefits are very cost effective. The benefit reduces unplanned births and the associated medical expenses.

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Writing in Today’s Hospitalist, Dr. Stella Fitzgibbons offers specific and useful advice to physicians who have to deal with the wishes of a family when a patient can longer speak for him or herself. I’m confident that her approach will yield constructive results in most situations, but I’m uncomfortable with the shortage of empathy and reflectiveness that the article ultimately conveys.

The scenario she introduces is as follows:

[W]hat about a patient who can no longer speak for himself—and family members who either seem unrealistic about the effectiveness of medical treatment or actually refuse to honor his wishes? What about a doctor’s duty to relieve suffering and not provide treatment the patient wouldn’t want ow that does him no good?

To summarize, here are the tactics Fitzgibbons recommends:

• Be sure all the doctors seeing the patient are saying the same thing –so that a doc who doesn’t like to give bad news doesn’t inadvertently give the family the idea that a cure is possible
• Get records from prior physicians –since families may transfer patients from hospital to hospital until they hear what they want
• Present facts and show them CTs. “Make it clear that the patient’s doctors know what is wrong and are not just speculating”
• Bring in a neurologist you trust so “the family can’t claim that he’s unqualified to talk about the prognosis”
• Find a chaplain who will be on your side
• Seek help from legal staff so you can ignore the family’s wishes and use the patient’s advance directive
• Persuade the patient that their “advisor” is less qualified than yours and that their stories of relatives who recovered are irrelevant
• If you think they are acting against the patient’s interests for their own gain, e.g., “they have been paying their own rent with his disability check” –then let the know you’re aware of it
• Stick to your principles since you know you’re doing the right thing for your patient

I don’t know the author and have no reason at all to distrust her motives. But I do get nervous about her level of certainty. In particular:

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Growing up in the suburbs in the 1970s and 80s I knew of teens experimenting with alcohol and marijuana. Cocaine, LSD, PCP and barbiturates were around, too, but pretty rare. I only knew of one teen who misused prescription drugs (in his case codeine). And if anyone in my area used heroin I would have been shocked.

Things have changed. In particular, strong opioids such as oxycontin are now widely prescribed. Teens may find some extras lying around in their parents’ medicine cabinets or even receive some themselves after an injury or medical procedure. Oxycontin has the veneer of respectability and the illusion of safety. After all it’s a commercially manufactured, legal product prescribed by a physician.

But it’s pretty easy to get addicted and that’s when the real troubles begin. Oxycontin is widely available on the street, but it costs about $1 per milligram in Boston, or $20 for a single 20 mg tablet. After breaking their piggybanks and using up their allowances, teens make a surprising discovery: heroin is much cheaper than oxycontin and produces the same effect. And that’s how good suburban kids become heroin addicts, even though they themselves and their parents would never have predicted it.

There’s a growing realization that this problem needs to be addressed. That’s a good thing for public health and also represents an opportunity for companies that can find a way to support these efforts.

New York State just released a report showing that narcotic prescriptions in the state increased 36 percent from 2007 to 2010. For Oxycontin the increase was a staggering 82 percent. Pharmacists are already required to report on sales of controlled substances every 45 days, but new rules would require them to scrutinize patients’ prescription records before filling and to report each filled prescription

Pharmacists would face significant fines for not checking prescriptions. Predictably the state pharmacist association is up in arms, calling such measures “ridiculous” and asserting that regulators don’t understand what the workflow is like behind the counter.

The New York proposal may not be optimal. Nonetheless public officials are justified in taking tough measures. The  proposed requirements do seem somewhat onerous. But that creates a business opportunity for those software and workflow companies that can develop effective and efficient data collection, analysis and reporting tools to aid pharmacists, physicians and public and private payers in addressing this problem without losing productivity.

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As we start the New Year folks are naturally thinking about containing health care costs both on a macro level (through the 2012 elections) and at the micro level (through managing their own expenses). Over the last couple years consumers have learned to use deal sites like Groupon and LivingSocial, so it’s natural that we’re seeing an interest in the same sites and approaches for health care.

I’m quoted in an Associated Press article on the subject (see it here on the CBS News site) and it was also written about on the Daily Kos. In general I’m pretty negative on the concept, though I don’t fault patients or providers for giving it a shot.

For a more in depth look, see my October 2010 Groupon and health care: a few thoughts and a separate interview with Groupon.

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Health and Human Services Secretary Kathleen Sebelius overruled the FDA to prevent the plan B emergency contraceptive from being offered without a prescription to girls under 17. The practical impact is to limit access to the “morning after” pill. The drug will remain behind the pharmacy counter and those under 17 will need to get a doctor’s prescription before they can purchase it.

The official reasoning is that the data submitted did not prove it would be used appropriately by young girls. But in fact this is a highly cynical decision that has everything to do with the upcoming presidential election.

Consider:

• The decision of the HHS Secretary to overrule an FDA decision appears to be unprecedented
• The drug isn’t dangerous even when it isn’t taken properly
• The FDA made the applicant (Teva) jump through a lot of hoops for this submission, then reviewed the data thoroughly
• Scientific panels have been in favor of OTC use since 2003, but political pressure (at that time from the Bush Administration) kept access restricted. In 2005, assistant FDA commissioner Susan Wood resigned over political interference in Plan B

Obama came to office vowing to change course from the Bush administration by respecting science and supporting reproductive freedom. His supporters will be very disappointed in this decision. And yet it is the right thing to do from the standpoint of supporting Obama’s re-election and the move is unlikely to cost Obama votes. Political discourse has moved so far to the right over the past few years that the Obama Administration could have gone considerably further than it did (like pulling Plan B from the market entirely) and still be well to the left of the Republican candidates.

With Republicans treating Planned Parenthood (which historically had bipartisan support) like the Devil, calling Obama a socialist, Bernanke treasonous and treating talk of any new taxes as completely off the table, one really has to wonder where things are headed. An Obama supporter enraged by the Plan B decision would really have to think seriously before jumping over to support a Republican Party whose commitment to things long taken for granted –such as the right to abortion in the case of rape or incest and the legality of contraception — is unclear.

You can bet a decision to widen access to Plan B would have given Republican candidates plenty of fodder to go after Obama as pro-abortion and in favor of 11 year old girls having sex. He did the right thing politically.

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One of the striking things about people who live to very old ages is how spry and healthy many are until close to the end. There are exceptions of course, but in general the very old are a hopeful beacon for those who are younger. So I was happy to see a Wall Street Journal article (Living Lab Sets Up at a Seniors Residence), which profiles efforts by the Mayo Clinic to apply research on healthier aging to an old-age residence next door. The article introduced me to the term “health span,” defined as “the number of years living on one’s own and free of major disease.” That’s a great objective that conforms to how almost everyone wants to age.

Researchers –and presumably their subjects, too– are looking for ways to extend the health span and bring it as close to the lifespan as possible. Techniques include medication adherence apps, vital sign monitoring systems, and seeking medications to improve muscle function. The article doesn’t discuss non-medical interventions, but there is a photo of residents lifting weights so presumably that’s an important part of the approach. I sure hope so.

“If you can attack the intersection between aging and chronic disease, you could really improve the health and independence of older people,” says Dr. [James] Kirkland, [head of Mayo's Center on Aging].

“This could substantially decrease health costs, especially if we are able to extend health span and shorten the period of disability at the end of the life span,” he adds.

I hope it works out.

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Recently I heard a Rabbi discuss the prohibitions against bribes in Jewish law. He shared the Talmudic insight that “a gift blinds the eyes of the wise” and taught that this refers not just to obvious bribes but even to small, innocent-seeming gestures that appear too insignificant to influence another person but that actually do cause a conflict of interest. I told him this sounded very similar to contemporary relationships between pharmaceutical companies and prescribing physicians, where small gifts like pens and take-out lunches are tools of the trade –viewed as innocuous by their recipients but seen as a good investment by the givers.

I revisited a blog post I wrote on the topic back in 2006 along with a JAMA article (Health industry practices that create conflicts of interest: a policy proposal for academic medical centers) by Brennan et al. from the same era. I looked at the list of articles citing the Brennan piece to see if I could find something more current. Lo and behold I discovered Unconscious conflict of interest: a Jewish perspective by Gold and Applebaum in the Journal of Medical Ethics, which probes this issue in more depth. They write:

To me this is fascinating stuff and suggests that to truly avoid the unconscious conflict of interest in the pharma/physician relationship it would be necessary to cut off all contact between pharma rep and doctor. Even when a drug rep is prohibited from distributing tsotchkes or tapping his restaurant budget, the physician still knows the rep would give him things if he could. Under this logic, the “no see” policies of some physician organizations toward pharma reps make good sense.

There is another solution, which is to educate physicians about unconscious biases and the objectives and tactics of pharma companies, device companies, health plans, and other would-be influencers. Even better would be to couple this education with conscious efforts to counteract any biases that are introduced.

Physicians are notoriously skeptical of the notion that they are influenced by gifts large or small. Therefor the article wisely concludes:

For those disinclined to accept either the insights of sociologists and anthropologists or the findings of modern neuroscience on the tendency towards reciprocity in response to the receipt of gifts and favours, perhaps the wisdom of the ancients provides a reason to rethink the unconscious influence of even small benefits on physician behavior.

Share