Health Business Blog

President Obama and House Speaker Pelosi did a masterful job bringing the health care reform bill to fruition. A couple months ago after Scott Brown’s election here in Massachusetts it sure didn’t look likely a smiling Obama would be signing the measure today. And yet here we are. But it wouldn’t have been possible without help from the Republican party.

What am I talking about, you ask?

By and large the American people want to see bipartisanship. The Democrats bent over backwards to include Republicans in drafting the health reform bill. Sen. Max Baucus in particular worked hard to bring along Chuck Grassley and Olympia Snowe. As Noam Schreiber points out in The New Republic:

“In retrospect, it appears that Baucus’s Republican interlocutors… either were never really serious about cutting a deal or, more likely, came under so much pressure from their GOP colleagues that they couldn’t cut one even if they wanted to.”

And House Republicans were like sheep: not a single one was prepared to vote for reform.

Republicans have tried hard to make it look like they are the ones being done down, with continuous exhortations to “start over” and “work with us.” With hypocritical statements like this, it became fairly straightforward for Obama to orchestrate the so-called “bipartisan health care summit.” At that meeting it became clear to the average American that Obama was trying harder at bipartisanship than the Republicans. The icing on the cake was when Obama signaled his willingness to adopt some Republican suggestions coming out of the summit.

My biggest chuckles have been with Republicans complaining about Democrats using unfair processes and not accepting the will of the people. I might have taken that notion seriously 15 years ago but after two George W. Bush terms the Republicans have absolutely zero credibility in this regard. An even bigger laugher was the attempt to cast aspersions on the bill with references to its length.

At the end of the day, the American public as a whole is likely to conclude that the Democrats played fair and thought for themselves. After all, unlike Republicans, not all Democrats voted in lockstep.

I also think that Americans may look negatively at some of the recent behavior displayed by Republican members of the House, including Rep. Randy Neugebauer calling anti-abortion Democratic Rep. Bart Stupak a “baby killer,” and Republican Congressman cheering protesters in the gallery who broke the rules by shouting “Kill the bill.” All of this follows on Rep Joe Wilson’s heckling of the President with his famous, “You lie.”

Count me among those who would like to see bipartisanship. In particular I wish Congress could have worked together to craft a bill that did more to promote inter-generational equity. It was galling to me to see Republicans denouncing potential cuts to Medicare in order to score points with seniors by scaring them about health care reform. It’s totally unprincipled. And I’m upset that there is some closing of the doughnut hole for Medicare prescription drug benefits in this bill. If anything the hole should be widened or the doughnut (i.e., Medicare Part D) be taken away completely.

Don’t be shocked  when in a few years –once the excitement of the current moment passes and attempts at repeal fade away– to see Republicans defending Federal health care spending that’s part of the current bill.

You don’t really expect Republicans to run on a platform of restoring the ability of health insurers to discriminate based on pre-existing conditions, do you?

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A baby boomer client of mine (in her late 50s) is fond of saying, “Mine will be the first generation to bring their laptop with them to the nursing home.” Kind of a scary thought, and probably true.

In the meantime these older boomers are taking care of their aging parents and turning to new technologies to do so. I got an email from the CEO of CarePilot, which bills itself as

The “first vertical search engine for comparing home health care providers in communities throughout the US…

Just as “Baby Boomers” have used the Internet to manage their communication, financial, shopping, entertainment, and travel-related activities, CarePilot believes that they will also turn to the Internet to research, select, and connect with home health providers for their aging parents…

We are not simply another social networking site, rather we offer our users the ability to share and communicate with each other via CarePilot connections, as well as the ability to research care providers using our database of more than 8,000 home health agencies throughout the US

It’s an interesting model: combining research tools and social networking and I’ll be interested to see whether it can prosper. Social networking is a hard thing to orchestrate. It helps to have a niche audience that has a major unaddressed, sustained need. PatientsLikeMe fits that description, giving otherwise isolated ALS patients (their first target) the opportunity to share information on how to improve quality and length of life for a disease that kills within a few years.

I can see the need for information when selecting and managing a home health agency and the site should be able to serve as a useful forum for people to share advice. There will be some challenges:

• The site is just launched, and the conversations are being seeded by a few early users and staffers. They’ll need a critical mass of regular users
• Caregivers tend to be quite time-pressed so they may not get into extended back and forth discussions that help such forums thrive and be remunerative for their owners
• Some of the useful information will be about specific, local agencies. There are so many agencies out there it may be hard to get enough discussion going about any individual one

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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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