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Dermatology, Ethics, Health Costs, Research, Stanford News

Drug samples lead to more expensive prescriptions, Stanford study finds

Drug samples lead to more expensive prescriptions, Stanford study finds

drugs on money - big

It’s been years (fortunately) since I’ve needed a prescription for anything more than a simple antibiotic. But when I did, I remember I was always thankful on those occasions when my doctor offered a free sample of a medication to try before (or sometimes instead of) pulling out the prescription pad. I appreciated the chance to see if a medication would work for me, and I was happy for any opportunity to save myself (or, at times, my insurance company) a few dollars. The fact that the samples were invariably for drugs that were still on patent (known as brand name drugs or branded generics) to a particular company certainly escaped me.

Now, a study by Stanford dermatologist Al Lane, MD, highlights the dark side of such free samples, which are provided to doctors by the pharmaceutical companies who make the drugs. The research, along with an accompanying editorial, is published today in JAMA Dermatology. As Lane comments in my release on the work:

Physicians may not be aware of the cost difference between brand-name and generic drugs and patients may not realize that, by accepting samples, they could be unintentionally channeled into subsequently receiving a prescription for a more expensive medication.

Specifically, Lane and medical student Michael Hurley found that dermatologists with access to free drug samples wrote prescriptions for medications with a retail price of about twice that of prescriptions written by dermatologists without access to samples. All of the patients had the same first-time diagnosis of adult acne. The difference is nothing to sniff at – $465 for docs who accepted samples and about $200 for docs who did not. What’s more, the overall prescribing patterns of the two groups of physicians showed almost no overlap. Physicians without access to samples prescribed mainly generic drugs (83 percent of the time), whereas those with access to samples prescribed generics much less frequently (21 percent of the time). Only one drug of the top ten most commonly prescribed by physicians without access to samples even made it into the top ten list of physicians who did accept samples.

The distribution of free drug samples in this country is big business. It’s been estimated that pharmaceutical companies give away samples of medications with a retail value of about $16 billion every year. But many physicians feel the availability of samples doesn’t sway their prescribing choices, and instead feel the samples allow them more flexibility to treat their patients. Lane himself thought so, until Stanford Medicine prohibited physicians to accept samples or other industry gifts in 2006. As he explains in the release:

At one time, we at Stanford really felt that samples were a very important part of our practice. It seemed a good way to help poorer patients, who maybe couldn’t afford to pay for medications out-of-pocket, and we had the perception that this was very beneficial for patients. But the important question physicians should be asking themselves now is whether any potential, and as yet unproven, benefit in patient compliance, satisfaction or adherence is really worth the increased cost to patients and the health-care system.

Clearly Lane has had a change of heart, in part based on the data in the study. Now he’s hoping to get the word out to other physicians. He and Hurley conclude in the paper, “The negative consequences of free drug samples affect clinical practice on a national level, and policies should be in place to properly mitigate their inappropriate influence on prescribing patterns.”

Previously: Consumers’ behavior responsible for $163 billion in wasteful pharmacy-related costs and Stanford’s medical school expands its policy to limit industry access
Photo by StockMonkeys.com

Chronic Disease, Health Costs, Patient Care, Stanford News

Stanford Coordinated Care: A team approach to taming chronic illness

Stanford Coordinated Care: A team approach to taming chronic illness

team handsNearly two years ago, Stanford began an experiment in medical care, a novel way to bring down the extravagant costs of health care while improving people’s health and their experience with the system. If you ask Shelly Reynolds, RN, one of the first patients to benefit, she will tell you it’s been a wild success.

“They hold me accountable for my own health, which is great,” she told me for my recently published Inside Stanford Medicine story. “Physically and emotionally, I’m healthier than I was before.”

And the experiment is costing less, according to initial figures.

The experiment is called Stanford Coordinated Care, a clinic aimed at helping those who consume the lion’s share of health care dollars. These are patients with chronic illnesses, like diabetes or asthma, who often wind up in emergency rooms or in the hospital because their conditions aren’t being well-managed.

The clinic helps them gain control over their health through a personalized approach by a team of caregivers who are available day or night and who give them the tools and support to manage their conditions at home. It focuses on the patients’ goals and what is important to them.

“It’s easy to make a diagnosis of diabetes, but it can be hard for a person to manage day by day,” Ann Lindsay, MD, one of the clinic co-directors, commented. “We help patients in developing a plan. We support it, and we empower them along the way.”

The clinic is the brainchild of Arnold Milstein, MD, a professor of medicine at Stanford and nationally known health care innovator. He developed a model, called the “ambulatory caring ICU,” which was tested successfully in several major pilot sites around the country. He wanted to bring the model to Stanford and recruited the husband-and-wife team of Alan Glaseroff, MD, now a professor of medicine at Stanford, and Lindsay, who had led one of the sites in California’s Humboldt County.

The clinic now has more than 200 patients, all employees and their families at Stanford University and Stanford Hospital & Clinics. Glaseroff calculates that among the first 27 patients treated in the first six months of the clinic’s opening in May 2012, it saved about $420,000, a 39 percent decline in costs from the previous six months, when patients were receiving care elsewhere. He said the numbers are still small and that research is under way to determine if the model is effective in reducing costs, improving outcomes and promoting patient satisfaction.

Initial findings show patient satisfaction at 100 percent. Reynolds is a good example: Working with Lindsay, she has developed a plan to effectively manage her asthma and her back pain and keep her out of the emergency room. She no longer feels like “a number” in the health care system and says having support from Lindsay has made all the difference: “For the first time in a long time,” she told me, “I felt that someone was looking out for me, advocating for me. It was such a relief.”

Previously: Focusing on the whole person to treat chronic disease – and cut costs, At-home program aimed at helping patients with chronic illness and Innovative Stanford clinic to support chronic care patients
Photo (modified from original) by bibendum84

Emergency Medicine, Health Costs, Research, Technology

Can sharing patient records among hospitals eliminate duplicate tests and cut costs?

566748316_7b72d5b777A recent analysis of the impact of health information exchanges, which allow health-care providers to share patient records electronically and securely, shows the systems hold promise for reducing health costs and unnecessary care in emergency departments.

For the study (subscription required), University of Michigan researchers examined information on hospital health information exchange participation and affiliation from the Health Information Management Systems Society’s annual survey as well as data the  California and Florida state emergency department databases from 2007 through 2010. Both states were early adopters of health information exchanges. According to a university release:

The findings show that the use of repeat CT scans, chest X-rays and ultrasound scans was significantly lower when patients had both their emergency visits at two unaffiliated hospitals that took part in a [health information exchange]. The data come from two large states that were among the early adopters of [health information exchanges]: California and Florida.

Patients were 59 percent less likely to have a redundant CT scan, 44 percent less likely to get a duplicate ultrasound, and 67 percent less likely to have a repeated chest X-ray when both their emergency visits were at hospitals that shared information across an [health information exchange].

More research is needed to determine the value of health information exchanges on patient care and health-care costs. But in order to conduct future analysis, said study authors, more states need to report relevant data to the Healthcare Cost and Utilization Project system  to allow researchers to view the activity of individual patients across their different medical encounters, while preserving patient privacy.

Previously: Experts brainstorm ways to safely reduce health-care costs, U.S. Olympic team switches to electronic health records and A new view of patient data: Using electronic medical records to guide treatment
Photo by Tabitha Kaylee Hawk

Health Costs, Health Policy, In the News

Is “Big Med” the future of health care?

The current special issue of the Journal of the American Medical Association takes the history and vitals of the U.S. health-care system’s finances. And, as NPR’s Shots blog reports, experts conclude that the cost of “drugs, hospital stays, doctors and bureaucracy” – rather than the number of diagnostic tests ordered or the size of the aging Baby Boomer population – accounts for over 90 percent of spending increases on health care since 2000.

What’s the prognosis? Maybe the large and concentrated market power of “Big Med,” says the Shots piece, borrowing the term from a JAMA analysis. But, like big airlines, the consolidation of services into fewer large bodies could produce better efficiency and safety while leading to a loss of quality in the consumer experience.

Previously: Making health care better and more affordableThe history of U.S. health care in about 1,000 words, An expert’s historical view of health care costs, Stanford expert urges physicians to take the high road in slowing health care spending and Does the Affordable Care Act address our health-cost problem?

Health Costs, Medicine and Society, Orthopedics, Research

How much for those healthy knees?

How much for those healthy knees?

hurt kneeWhat’s the cost of healthy, functional knees for life? Priceless, you might say, especially if yours feel achy or injured. But rehabilitation after a major injury, such as an anterior cruciate ligament (ACL), can be expensive, and results after surgery vary.

A recent study published in the Journal of Bone and Joint Surgery has examined the cost-effectiveness and quality-of-life impact of surgery to repair an ACL tear in relation to the price of the procedure, versus rehabilitation without surgery. Researchers found the average lifetime societal benefit of having ACL reconstruction surgery to be $50,000 per patient – or $10.1 billion across the U.S., which reports approximately 200,000 ACL tears annually.

This price includes not only money that would have been spent on rehabilitation and future injury repair, but also comparative lost wages and disability payments after surgery versus non-surgical rehabilitation. It also considers the patient’s ability to live with high function, low levels of pain and minimal risk of developing knee osteoarthritis.

From the study:

In the short to intermediate term, ACL reconstruction was both less costly (a cost reduction of $4503) and more effective (a [quality-adjusted life years - QALY] gain of 0.18) compared with rehabilitation. In the long term, the mean lifetime cost to society for a typical patient undergoing ACL reconstruction was $38,121 compared with $88,538 for rehabilitation. ACL reconstruction resulted in a mean incremental cost savings of $50,417 while providing an incremental QALY gain of 0.72 compared with rehabilitation. Effectiveness gains were driven by the higher probability of an unstable knee and associated lower utility in the rehabilitation group. Results were most sensitive to the rate of knee instability after initial rehabilitation.

Previously: Study shows men, rather than women, may be more prone to ACL injuries, Stanford study shows protein bath may rev up sluggish bone-forming cells andIron-supplement-slurping stem cells can be transplanted, then tracked to make sure they’re making new knees
Via Medical News Today
Photo by Carolyn Tiry

Chronic Disease, Health Costs, In the News, Patient Care, Stanford News

Focusing on the whole person to treat chronic disease – and cut costs

Focusing on the whole person to treat chronic disease - and cut costs

Yesterday’s Marketplace on NPR offered a look at the new – and cost-effective – way some doctors are treating chronic illness. Among those featured in the segment was Alan Glaseroff, MD, co-director of Stanford Coordinated Care:

“[Our] work begins by asking the question, ‘Why wouldn’t a person with a chronic condition do everything in their power to live long and feel well?’” he says. “And generally there is sort of a subtext, ‘What is wrong with this person, they are not listening to me.’”

At his clinic, Glaseroff sees 160 privately insured patients, who racked up $58,000 a year, on average, in medical bills before he began treating them.

Glaseroff directs his team to focus first on what matters to a patient like dancing at his daughter’s wedding, for instance. Then they deal with the fact that the patient is diabetic and smokes three packs a day.

Glaseroff says his approach has helped shave 20 percent off his patient’s medical costs. He says if the model succeeds in other states, “It will be a huge step forward.”

Previously: Innovative Stanford clinic to support chronic care patients

Health Costs, Health Disparities, Public Health, Rural Health

“Mountain Dew mouth” rots teeth, costs taxpayers

"Mountain Dew mouth" rots teeth, costs taxpayers

1527462651_903a291406“Blecch! Ew! Sheesh! I’ll take a crab juice,” replied a thirsty Homer Simpson to a vendor’s alternative offer of Mountain Dew. I side with Homer on most issues, including this one. But whatever you think of the taste, you’d be hard-pressed to argue in favor of the soft drink’s nutritional value.

Soda has a bad reputation for being high in empty calories that contribute to some of the nation’s public-health problems, such as obesity and diabetes. NPR’s The Salt blog reports today on a phenomenon widespread in Appalachia of rotting teeth owing to frequent consumption of soda. The incidence is called “Mountain Dew mouth” – “after the region’s favorite drink,” which was invented in Tennessee, the piece notes.

Public-health advocates point out a burden of cost imposed by the Dew, which can be acquired with food stamps (now called the Supplemental Nutrition Assistance Program). Greater access to the drink and limited availability of dental care contribute to “Mountain Dew mouth,” which is reinforced by cultural issues in the area.

From the piece:

Many people don’t trust the well water in their homes because of pollution concerns and probably drink more soda because of it, [Priscilla Harris, JD, an associate professor at the Appalachian College of Law], says. She’s received a grant from the Robert Wood Johnson Foundation to study the problem.

And there’s another reason why soda mouth is so pervasive in Appalachia, Harris says: the region’s distinct culture of sipping soda constantly throughout the day. Singer adds, “Here in West Virginia, you see people carrying around bottles of Mountain Dew all the time — even at a public health conference.”

The article reports statistics about the region’s rate of tooth decay as 26 percent for pre-schoolers, and tooth extraction because of decay or erosion as 15 percent for 18- to 24-year-olds. In West Virginia, Centers for Disease Control and Prevention numbers show 67 percent of residents age 65 and over having lost six or more teeth from tooth decay or gum disease.

Previously: Sugar intake, diabetes and kids: Q&A with a pediatric obesity expert and Dental health a major problem for many
Photo by uberculture

Ask Stanford Med, Health Costs, Research, Stanford News

What’s the going rate? Examining variations in private payments to physicians

What's the going rate? Examining variations in private payments to physicians

In this photo taken Tuesday, Sept. 2, 2009, University Muslim Medical Association Community Clinic family medicine physician Linh Vuong, right, checks vital signs of high school student Ericka Millan,15, at the UMMA Community Clinic in Los Angeles.  American Muslims want to ensure that they can fulfill "zakat," or obligatory charitable religious giving, following zakat pledge by President Barack Obama. (AP Photo/Damian Dovarganes)When a U.S. physician sees a patient – either for a routine visit or to administer some sort of treatment – there’s a good chance she’ll be paid a different amount for her work than another doctor doing the same thing one state, or perhaps even one county, away. Variation in the amounts that private insurers pay physicians is a known phenomenon, but extensive research on the practice – and the factors that account for such variation - has been lacking.

To better understand these differences in payments, Stanford health-policy experts Laurence Baker, PhD, and M. Kate Bundorf, MBA, MPH, PhD, teamed up with an Indiana University–Purdue University researcher to comb through more than 41 million insurance claims for four kinds of services: office visits with established patients, office visits with new patients, office consultations, and preventive visits with established patients. What they found was that physicians at the high-end of payments received were generally paid more than twice than what physicians at the low end were paid for the same service. They also found that the variation couldn’t be explained by patients’ and physicians’ characteristics – things like the age and sex of the patient, the physician’s specialty, and whether the doctor was a “network provider” – but that about one third of the variation was associated with the geographic area of the practice.

To find out more about the study, which was published online yesterday in Health Affairs, I contacted Baker. He answers my questions below.

Were you surprised by what you found?

Sort of. Some news reports have highlighted variations in health-care bills, so we were ready for some variations. But since we were looking at services that are quite common and pretty consistent from place to place, we weren’t expecting to find very big variations, which is what we got.

The other thing that’s interesting is the amount of variation that isn’t explainable by the things we looked at. I had expected a lot of it would be explainable, but most of it isn’t. This is another indication of the complexity of the health care system and the lack of understanding we have of the factors that determine prices.

Did you expect geography to be more of or less of a factor?

I had expected more. Geography is a proxy for many things – such as the costs in different areas, the competitiveness of areas, the preferences of the population and doctors. These could all influence prices. I had thought these would play a bigger role than what we found. But there’s a chance that these things still do, but in ways that are specific to individual doctors or groups, so that we need to do more work to fully measure them.

Why is a better understanding of price variation important?

Price variations could signal important problems with the functioning of health-care markets. Large price variations for similar services normally only exist where someone in a market has a lot of power to dictate prices, which is often a problem for consumers. Price variations can also exist for reasons we’d be less concerned about – for example, if some providers are much higher in quality than others. But knowing about the existence and patterns of price variations can guide us to examine areas that we may need to work on to improve the system.

Informing patients about price variations can also be important. Some patients – for example, the uninsured – can end up paying widely different prices for the same services. If they have more information, they’ll perhaps be better able to manage their health-care experiences and bills.

Continue Reading »

Aging, Chronic Disease, Health Costs, Medicine and Literature

Examining end-of-life practices and Katy Butler’s “Knocking on Heaven’s Door”

How long is too long to hang on when the end of life calls? Abraham Verghese, MD, Stanford physician and best-selling author, discusses the emotional and financial costs of extended end-of-life care in a New York Times book review of Katy Butler’s “Knocking on Heaven’s Door.” In the book, Butler details the drawn-out descent of her father after a stroke and sheds light on the unseen hardships of caring for the slowly dying, both for families of the ill and hired home workers.

From the review:

Butler finds that the health care system — and society — seem quite unprepared for a patient like her father. Had he received a diagnosis of a terminal illness, the family would have been supported by a Medicare-funded hospice team.

“But there is no public ceremony to commemorate a stroke that blasts your brain utterly, and no common word to describe the ambiguous state of a wife who has lost her husband and become his nurse.”

The review compares the sometimes six-figure cost of an end-of-life ICU stay to a home health-care worker’s salary, which Butler describes as typically “immorally low.”

Verghese writes:

My hope is that this book might goad the public into pressuring their elected representatives to further transform health care from its present crisis-driven, reimbursement-driven model, to one that truly cares for the patient and the family.

Previously: A conversation guide for doctors to help facilitate discussions about end-of-life careHow a Stanford physician became a leading advocate for palliative care, Honoring an exploration of the “cost of dying”, Exploring the psychological trauma facing some caregivers and Is $618,616 too much to (try to) save a life?

Health Costs, Health Disparities, Health Policy, In the News, Obesity, Public Health, Science Policy

Can food stamps help lighten America’s obesity epidemic?

shopping_12from SNAPIn a recent article in New Scientist, Peter Aldhous discussed several issues related to the Supplemental Nutrition Assistance Program, commonly referred to as food stamps. Noting that “because junk food is cheaper than fruit and vegetables, poverty and obesity tend to go hand-in-hand,” he offered several ways in which the program could be used to lower obesity and malnutrition rates among food stamp users. Here are some examples of the “economic carrots and sticks” he mentions in his piece:

One simple idea is to give the benefits every two weeks, rather than monthly. This would smooth out a cycle in which people load up on high-calorie food when the payments come in, then go hungry towards the end of the month – a pattern known to cause weight gain…

But most attention is focused on efforts to provide incentives to buy fruit and vegetables, or restrict purchases of junk food. A pilot project delivered promising results last month. Over 14 months to December 2012, 7500 households receiving food stamps in Hampden, Massachusetts, were given an extra 30 cents for every dollar spent on fruit and vegetables. Surveys run four to six months into the study show that their consumption of fruit and vegetables was 25 per cent higher than for people on regular food stamps.

Sanjay Basu of Stanford University in California has studied how changes in food prices affect what people put in their shopping baskets. His work suggests that banning food-stamp purchases of unhealthy foods, or increasing their price, should be even more effective…

If the food stamp program could be used to improve the diet of food stamp users, Aldhause writes, it could pave the way “for using taxes and subsidies to nudge the nation as a whole towards a healthier relationship with food.”

Holly MacCormick is a writing intern in the medical school’s Office of Communication & Public Affairs. She is a graduate student in ecology and evolutionary biology at University of California-Santa Cruz.

Previously: More evidence that boosting Americans’ physical activity alone won’t solve the obesity epidemicLucile Packard joins forces with Ravenswood School District to feed families during the summer breakFood stamps and sodas: Stanford pediatrician weighs inFood stamp use shows scope of child poverty and Denmark’s “fat tax” aims at life expectancy – not just waistlines
Photo by United States Department of Agriculture

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