Health Business Blog

The Health Business Blog is on vacation this week. Here’s a rerun of a post that originally appeared a year ago.

Last month I noticed that the store brand “pure” vanilla extract I had just purchased contained corn syrup, whereas the brand name version in my pantry didn’t. From the pharmaceutical industry I’m used to generic products being essentially identical to branded items, and I guess I just assumed the same was true with foods. Turns out that’s not the case, at least with vanilla.

I sent the following email to SuperValu, whose name was on the Shaw’s brand product, on December 18:

“In the past I have purchased McCormick Pure Vanilla Extract. This time I purchased Shaw’s Pure Vanilla Extract. When I compared the labels I was disappointed to see that while both products contain vanilla bean extractives in water and alcohol, the Shaw’s product also contains corn syrup.

How much corn syrup is in there and why?

It seems to me that it is misleading to refer to the product as pure and then include corn syrup. What do you think?”

I received a response within two hours. SuperValu didn’t know the answer but promised to check with the supplier to find out the answer within about five days. I was just starting to think they’d forgotten about me when I received the following email today:

“Dear Mr. Williams:

Thank you for taking the time to contact us. We welcome the opportunity to address your disappointing experience with our Shaw’s Pure Vanilla Extract.

Pure Vanilla has a standard of identity provided by the Federal Government. This means the formula must contain certain ingredients which are standard to that particular product.

The word pure indicates the vanilla flavor comes only from the extractives of the vanilla bean. The amber colored liquid known as pure vanilla must also contain, at least, 35% ethyl alcohol and is the extractives of 13.35 ounces of vanilla beans. Other optional  ingredients that may be added to pure vanilla are sugar or corn syrup which enhances the delicate vanilla flavor.

If you wish to respond to this note by e-mail, please include your name and e-mail address.

We hope to have the continued pleasure of serving you.

Sincerely,

[Name of  Person]
Consumer Affairs Specialist”

Interestingly, the email was from McCormick Consumer Affairs, which I assume means McCormick makes both the branded and store brand versions on sale at Shaw’s. That’s a different story from what I see on store brand OTC medicines, which often contain explicit labels indicating they are not made by the branded producer.

This Yahoo Answers page indicates that corn syrup is used to mask inferior beans, which sounds like a logical explanation. Even if the beans are the same quality it’s probably cheaper to include some corn syrup.

In any case, it’s back to the pricier brand name version for me next time. And I still think it’s misleading to call this product “pure” even if the government allows it.

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Smoking penalty: Individual health care coverage could become unaffordable for many people is the headline of an Associated Press editorial masquerading as a news story. The gist of the piece is that older smokers won’t be able to afford health insurance because health plans will be allowed to charge smokers up to 50 percent more than what non-smokers pay. The article strongly implies that the law is unfair to smokers and should be changed.

But rather than frame the piece as smokers not being able to afford health insurance, maybe AP should have described it as people not being able to afford to keep smoking. According to the CDC, about 70 percent of smokers want to quit, so perhaps the added financial inducement will succeed where other smoking cessation approaches have failed.

Smokers really do cost health plans more so it’s not as though the rule is without merit. And imagine how happy an ex-smoker will be when s/he saves thousands on health insurance and thousands more by not paying for cigarettes.

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In case you wonder why I criticized the article for being a masked editorial, here’s the lead paragraph:

Millions of smokers could be priced out of health insurance because of tobacco penalties in President Barack Obama’s health care law, according to experts who are just now teasing out the potential impact of a little-noted provision in the massive legislation.

Here’s what’s wrong just with that sentence:

• It’s not President Obama’s health care law. It was passed by both Houses of Congress and signed by Obama.
• Who says experts are “just now teasing out the impact” or that the provision is “little-noted”? This provision is pretty clear and wasn’t hidden.
• And what’s the point of calling the legislation “massive”? It doesn’t contribute anything to the story

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Republican Governors had been busy talking at –rather than with– the Administration about the Affordable Care Act. Now that President Obama has won re-election their tune is changing at least somewhat. Eleven Governors sent a letter asking to meet with the President to discuss the ACA and in particular to make their case that there should be more flexibility in how the law is rolled out. Signatories include Florida’s Rick Scott and Arizona’s Jan Brewer, both of whom have publicly insulted the President in the past.

No doubt there is some merit to the idea that states should have some flexibility in how they undertake health reform. On the other hand, by opposing the passage and implementation of Obamacare so vigorously –including suing the Feds, refusing to set up state health insurance exchanges, and opposing Medicaid expansion– these Governors have really been picking a fight.

Maybe the Governors should start their meeting with the President with an apology, because at this point the President is justified in shoving Obamacare down their throats.

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Health Wonk Review is up at Managed Care Matters.

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This is the transcript of my recent podcast interview with Doximity CEO Jeff Tangney.

Williams:            This is David Williams, co-founder of MedPharma Partners and author of the Health Business Blog.  I’m speaking today with Jeff Tangney.  He is co-founder and CEO of Doximity.  Jeff, thanks for being with me today.

Tangney:            Thanks David.  Great to be here.

Williams:            Jeff, with so many existing social networks out there, why would you start a new one?

Tangney:            Good question.  All of us feel we’re getting all these notifications and updates and requests, but as a physician, there’s actually no good way to communicate with other physicians.

Email is illegal because it’s not HIPAA compliant. Neither is texting.  Today, if a physician wants to get –for example– a lab value on a patient that they saw last week, most of it happens over the fax machine.  In fact, 15 billion faxes were sent in health care last year in the United States.

We’re making that whole process a little easier, a little bit more like the teenager sitting in the patient waiting room on Facebook or Twitter and a little less like the 1970s.

Williams:            It’s amazing –the fax machine.  It’s the seventh birthday of the Health Business Blog; seven years ago in one of my first posts I wrote about my disbelief that fax machines were still around.  And they’re still with us today.  Maybe in another seven years they’ll slow down a bit.

Tangney:            They’re going strong.  Our goal is to rip it out of the wall.

Williams:            You mentioned similar functionality to Facebook or other mainstream social networks.  How does the functionality of Doximity compare to LinkedIn or Twitter or Facebook?

Tangney:            Reid Hoffman from LinkedIn has a good quote which is that today’s online social networks are really just representations of the offline networks that we’ve had for lifetimes. Facebook is the backyard barbeque, LinkedIn is the corporate office; who’s getting promoted, who isn’t, and Twitter is the bar; people talking about the latest news.

We’re bringing in the hospital; the place where you can have those HIPAA compliant discussions.  We offer authentication of every user.  You not only tell us you’re a doctor, you have to prove that you are.  That allows folks to have HIPAA compliant discussions about patients.

We work on the iPhone, the Android and the web.  About three-quarters of our use is actually on mobile devices because doctors are more mobile than your typical professional.  They can take a photo of a tough case on their iPhone and post that.   We offer iRounds, a curbside consult forum organized by specialty.  That’s not something you would find in your typical forum.

We also do a lot in pre-loading. We pre-populate the CVs of all of our doctors.  We know what articles they’ve published, what clinical trials they’ve done, what insurance they accept, their office phone and fax from a number of public databases. So that even if someone is not yet a member of the network  (and today we have about 8% of U.S. physicians as active members) another doctor can still look them up and find their basic office, phone, fax and clinical history.

Williams:            Do you integrate with other social networks like for example Twitter?  Some of the things I tweet might still be relevant within Doximity.  Is there a way to bring tweets over the wall or is that not part of what you do?

Tangney:            David, I’m guessing you’ve used the product.  Yes, actually that’s one of the popular features.  Doctors who are on Twitter can actually tweet and add a #dox.  You’ll see it in a lot of places these days and that will automatically bring it into their Doximity stream.

Also we integrate with LinkedIn and Facebook.  A lot of people pull over their profile.

Our goal is to provide a place that is safe to talk about patient issues.  It is recreating that offline doctor’s lounge in some ways.  Integrating with these other networks we view as positive.

Williams:            There are some physician-only platforms already.  Sermo is one example. Your prior employer, Epocrates is another platform.  Is there a relationship between Doximity and those?

Tangney:            Sermo is a physician only network, but all the physicians who participate in it are anonymous so that they have a “handle,” nightdoc2 for example.  The discussions tend towards politics.  It’s an interesting social case study.  When you let people wear masks, they have a different discussion than if they’re there as their real person.  There’s a place for Sermo, but we’re offering something quite a bit different.  When you have a real name authenticated network, people discuss different things.

I was one of the two founders of Epocrates and was president and COO for about ten years.  I have a long history and great knowledge of Epocrates.  I left there about two years ago.  We do partner with Epocrates on some things.  Epocrates really isn’t a physician network.  It’s a clinical reference that’s used on iPhones.  We’re evaluating other partnership opportunities that are down the road.

Williams:            One topic that people are always interested in as it relates to social networks is the business model.  What kind of a business model do you have today and what are you expectations about its evolution?

Tangney:            Today we make money from market research firms; Gerson Lehrman Group, Coleman Research Group.  Such firms paid over $100 million last year to physicians in the U.S. in honoraria, typically to talk with someone who needs their expertise.  It’s a hedge fund manager who wants to know what you think of this new stent that just got approved or it’s a medical malpractice lawyer who wants your quick opinion on who the top experts in this area might be.

We require that they pay our doctors a minimum of $250 per hour. In most cases it’s been around $500 per hour. We provide them a LinkedIn for doctors, a place where they can find who really is the expert on specific subjects  –for example neuroendocrine tumors because they have a reporter who wants to talk about Steve Jobs’ disease.  We charge the market research firm a matchmaking fee of $200 per doctor. It’s been a decent revenue source for us and for our member physicians.

Down the road this certainly will evolve.  There are a lot of other directions that we can go.  We have some hospitals, some alumni associations who are partnering with us and paying us to host their medical networks.

As we learned at Epocrates there are a lot of different players who are interested in a physician audience.  Physicians make billions of dollars of decisions every year. Our goal here is like we did at Epocrates, to walk that line, not to make it crass advertising but to offer platforms for folks to communicate about the newest treatments, the newest CME and those types of things.

Williams:            You mentioned that you have about 8% of U.S. doctors on your platform.  Say a little bit more about that in terms of what the typical user profile is and also how you measure utilization.  What are the metrics that are relevant here and what are you achieving?

Tangney:            We are 8% today.  We’re adding about 1,000 new doctors a week right now so we’re continuing to grow at an accelerating pace.

Our average physicians have profiles that are 57% complete.  That means that they have filled out more than half of the fields that we have on our profiles; education including undergrad and medical school, residency and fellowship, work history, clinical interests, faculty, photos, titles, the insurance they accept, and ACOs or medical groups they’re part of or affiliated with or hospitals they’re affiliated with.  Those are the various things that are all very searchable.  Our average user fills in slightly more than half of those.

Our utilization is something that we look at very closely.  We have utilization that is several times LinkedIn. We have about three times as many U.S. doctors on Doximity as are currently on LinkedIn.  Our utilization s well above 10% per week that are coming back and using us to send a message to another doctor or read a news post on iRounds.

As we grow the network, we see that people are finding more people that they know and are more and more likely to use it.  That engagement stat we measure on a weekly basis and it’s continuing to grow.

Williams:            Can you provide an example of a doctor using Doximity to achieve something for a patient that would not have been possible without Doximity?

Tangney:            We’ve got a bunch of examples.  We’ve had a least a dozen major cases solved on iRounds.  One example is a pediatric gastroenterologist in Texas who is the expert in Texas on treating pediatric gastric disorders. He had a patient who he just couldn’t figure out and he posted about the patient in a moment of distress; “Does anyone know what to do?”  He got a reply from a doctor in California who was just finishing a clinical trial on a new type of treatment that has been recently published.  Through that dialogue he was able to find a new course of treatment for his patient and solve her problem.

We had an ER doc, a surgeon who posted about a patient he had seen who had accidentally swallowed a metal bristle from a grill brush.  It had mistakenly gotten into his hamburger and it perforated his intestine.  He posted it as what he called a fascinoma; an interesting and rare case.  He actually found two other emergency room physicians who had encountered the same thing in the last year and so now they’re asking, ah ha, I wonder how common this is.  They are writing a paper on safety standards around grill brushes because if grill brushes are a problem and will perforate bowels across the U.S. they thought that they should bring that to people’s attention.

Williams:            My image of somebody who would be on a service like Doximity is somebody younger, maybe right out of residency.  Is that accurate or what are you seeing in terms of diversity of profiles and users?

Tangney:            Our average age is 40, but it’s a bimodal distribution.  In other words there are some of the young doctors –fewer residents but more fellows.  These are folks who have just finished ten years of training and are hanging out their shingles now, for example as a thoracic surgeon. They are super connectors.  They are the ones who have the greatest business need to stay connected to primary care physicians and referral sources in their areas.  They have the greatest number of colleagues on the network.  They have the greatest amount of activity.

Then we see another bump in the late 50s where you see physicians who realize they’re falling a little out of touch or that they have more time to reengage with some of this technology.  They’re great.  They’re some of the best responders to these types of questions because they have decades of experience and they’re in a place where they have some time now to give back, to mentor, to help folks who haven’t had as much experience.

You’re right that the busy years in the middle, those 40s, they’re our later adopters.  The users are mainly younger docs.  Then we have little blip again in the late 50s and 60s.

Williams:            Doximity strikes me as tool that would be very useful for an independent physician.  How does it fit in with some of the trends toward provider integration?  I’m thinking about phenomena like patient centered medical homes or accountable care organizations.  Would you see yourself having corporate customers or people that are using it as more of an enterprise product?

Tangney:            Yes.  You’re right that private practice physicians see us as having value as a referral network tool, absolutely.  We have 600 doctors from Kaiser Permanente who are in our network, which is more than I ever expected to get.  When you boil it down, even though they’re inside Kaiser and don’t worry about referrals very much and it’s a completely closed system, they still need to collaborate. The tools that they have today don’t have secure texting –and we do.

They don’t have a quick way of pulling up their colleagues’ training just to see for example who wrote the paper on laparoscopic hysterectomies.  We provide them an easy way of doing that and that’s an additional social layer over a lot of the EHR and other systems that they’re currently using.

Williams:            I’ve been speaking today with Jeff Tangney.  He is co-founder and CEO of Doximity.  Jeff, thank you very much for your time.

Tangney:            Great, thanks David.

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

I was in the pharmacy recently and saw that Colgate has added a Total Gum Defense line extension to its already large set of Total products. But this product makes exactly the same set of claims as the regular Total –”Helps prevent: Cavities, Gingivitis, Plaque. Fights Tartar, Freshens Breath, Whitens” –and lists the same active and inactive ingredients. Then yesterday I was at the dentist’s office, where there was a big basket of Total Gum Defense samples. I asked a periodontist there if there was any difference and she said, “Not as far as I know.”

I poked around the Colgate website and couldn’t find any differences mentioned there. (Could be hiding somewhere but it wasn’t apparent.) I did find it instructive that the site lacks the ability to compare the various Total products head-to-head, probably because the main differences are how they’re positioned to the market rather than anything substantive.

Finally I called Colgate customer service to ask my question. Judging from how quickly they came up with an answer, this is clearly a question they’ve been receiving a lot. The rep pointed to two differences:

• The formulation is milder –using a different type of hydrated silica
• The flavor is less minty –presumably making it more tolerable for those with sensitive gums

I guess it’s enough of a difference to be plausible, and maybe labeling regulations prevent them from being more explicit. But my guess is that Colgate Total Gum Defense is just a typical consumer product line extension, designed to grab a little more shelf space, appeal to a few more consumers, maintain price premiums, and keep generics at bay.

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I was in the pharmacy recently and saw that Colgate has added a Total Gum Defense line extension to its already large set of Total products. But this product makes exactly the same set of claims as the regular Total –”Helps prevent: Cavities, Gingivitis, Plaque. Fights Tartar, Freshens Breath, Whitens” –and lists the same active and inactive ingredients. Then yesterday I was at the dentist’s office, where there was a big basket of Total Gum Defense samples. I asked a periodontist there if there was any difference and she said, “Not as far as I know.”

I poked around the Colgate website and couldn’t find any differences mentioned there. (Could be hiding somewhere but it wasn’t apparent.) I did find it instructive that the site lacks the ability to compare the various Total products head-to-head, probably because the main differences are how they’re positioned to the market rather than anything substantive.

Finally I called Colgate customer service to ask my question. Judging from how quickly they came up with an answer, this is clearly a question they’ve been receiving a lot. The rep pointed to two differences:

• The formulation is milder –using a different type of hydrated silica
• The flavor is less minty –presumably making it more tolerable for those with sensitive gums

I guess it’s enough of a difference to be plausible, and maybe labeling regulations prevent them from being more explicit. But my guess is that Colgate Total Gum Defense is just a typical consumer product line extension, designed to grab a little more shelf space, appeal to a few more consumers, maintain price premiums, and keep generics at bay.

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Consumer Reports features “Your Security” on its cover and includes articles on keeping a home and family safe. There are a couple good ideas on health care related topics.

1. Shred anything you get from your health insurer, such as Explanation of Benefit forms
2. Destroy the labels on your prescription medications before discarding

Information on these items –names, phone numbers, date of birth, doctor and insurance info– could be useful for identity thieves. If you value your privacy you might want to follow these tips for that reason, too.

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Christoph Westphal is a very intelligent person, otherwise he would not have been granted an MD/PhD from Harvard and a BA (Phi Beta Kappa) from Colombia. And he wouldn’t have founded various biotech companies or been named to head GSK’s venture arm. Yet it doesn’t take someone with an advanced degree to realize something is wrong with his op-ed (The myth of the perfect drug) in yesterday’s Boston Globe.

Here’s how it starts:

When it comes to prescription drugs, patients expect benefits but appear intolerant of risks. What would happen in a world that accepts no risks in its pharmaceuticals? We would have very empty medicine cabinets.

The rest of the piece describes how patients have over-reacted to the risks of Vioxx, and repeats the tired assertion that “it is possible that aspirin would not be approved today by the FDA, so dramatic is the shift in society’s risk-benefit views regarding pharmaceutical products.” (I first heard that line back in 1994.)

Three times in the space of two columns, Westphal writes of the benefits of Vioxx in “severe arthritis.” He keeps warning that “society” is making a mistake by over-weighting the risks relative to the benefits.

In placing the blame on “society” for shifting its view of the risk/benefit tradeoff, Westphal is ignoring a number of important elements in the Vioxx saga. In particular, Merck, medical journals and the medical profession are to blame:

• Merck heavily promoted the drug beyond patients with “severe arthritis.” One of my relatives (also Harvard educated, but just a Master’s degree) was prescribed Vioxx for moderate arthritis pain. She didn’t ask her doctor for the prescription; he prescribed it based on its presumably benign profile. In fact, when Vioxx was originally approved one of the big marketing pitches was that it was safer than over the counter pain relievers. My relative was livid when she found out about the dangers, and rightly so
• The New England Journal of Medicine published a flawed article on the VIGOR trial, which played up the benefits of Vioxx and downplayed the risks. When issues were pointed out after publication, the Journal argued that it didn’t have the resources to ferret out problems in articles. Meanwhile, the Journal sold more than 900,000 reprints of the article –more than one for every practicing physician in the country– and most of those were purchased by Merck. I’m sure they weren’t all given to docs prescribing for “severe arthritis.” I’ve proposed a “100,000 reprint rule” that says journals should spend more effort on follow-up of especially popular articles
• Some physicians have allowed their trust and authority to be co-opted by pharmaceutical companies. By accepting promotional items and free CME, by allowing articles to be ghost written, by relying on drug reps to educate them on medications, they have not lived up to the standards that society expects. Certain drugs are available by prescription-only because doctors are supposed to be looking out for the patient. Sadly sometimes physicians have failed us

In light of these behaviors, it’s entirely reasonable for consumers (i.e., society) to become more risk-averse and for the government to step in. It’s odd that Westphal wrote a whole article blaming society without once acknowledging the role his industry and profession have played in getting us to this point. A little bit of introspection is called for here.

For the record, I am in favor of allowing even medications with dangerous side effects and potential for abuse on the market. But we need pharma companies to be ethical, journal editors to be diligent, and doctors to put patients first. Get those things straight and then we can talk about societal issues.

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I’ve been on vacation this week so no posting.

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