Tag: cost

Blog Posts (17)

November 15, 2016

Making Progress in Improving End-of-Life Care

This past week the JAMA Network and the Kaiser Family Foundation published a one-page graphic providing the latest data and information about Medicare patients and end-of-life care. JAMA. 2016;316(17):1754. In 2014, there were 2.6 million total deaths in the US; 2.1 million or about 80% of the total were persons covered by Medicare. These 2.1 million 2014 Medicare decedents accounted for 13.5% of all Medicare spending. That is about $35,529 per Medicare beneficiary who died in 2014. Other Medicare beneficiaries – those who did not die in 2014 – cost the system about $9,121 per person. This is a remarkable difference from 1978, when Medicare decedents in the last year of life accounted for 28% of program expenditures. Lubitz JD, Riley GF. Trends in Medicare payments in the last year of life. N Engl J Med. 1993;328(15):1092-1096. Interestingly, the percentage between 1978 and 1988 did not change.

The new data show that trends have changed over the intervening decades. One of the more definitive descriptions of Medicare expenditures for beneficiaries in the last year of life was published in the New England Journal of Medicine in 1993. Lubitz JD, Riley GF. Trends in Medicare payments in the last year of life. N Engl J Med. 1993;328(15):1092-1096. In some respects the data may not be exactly the same, for example, one compares payments in calendar years, and the other the last 12 months of patients’ lives; but the trends are fairly clear anyway:

·         In 1988, Medicare charges for decedents were 6.9 times those for other Medicare patients. In 2014, Medicare charges for decedents were 3.7 times those for other Medicare patients. That was a 46% reduction in charges for end of life care from 1988.

·         In looking specifically at the 65-year-old range age group of Medicare beneficiaries who died in 1988 and 2014 respectfully, decedent charges were 10.6 and 7.4 times higher than other Medicare beneficiaries in the category. This was a 30% reduction in charges for end-of-life care from 1988.

·         In 2000, about 21% of Medicare patients who died that year received hospice care; in 2014, about 46% of Medicare patients who died that year received hospice care. The number of dying Medicare patients referred to hospice over the 14-year period more than doubled.

·         In 2000, total Medicare hospice spending was $2.3 billion; in 2014, total Medicare hospice spending was $10.4 billion. This was a 352% increase over the 14-year period. This growth comes primarily from the time a Medicare decedent is enrolled in a hospice program. The median length-of-stay in hospice has increased from 15 days in 1994 to 18 days in 2014, but the level of hospice services provided was enhanced. Taylor DH Jr, et al. What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Social Science & Medicine. 2007;65(7):1466-1478. Curiously, the percentage of adult patients who died within 7 days of entering hospice care services increased from 22.8% in 1992 to 35.5% in 2014. Han B, et al. National trends in adult hospice use: 1991-1992 to 1999-2000. Health Affairs. 2006;25(3):792-799. National Hospice and Palliative Care Organization 2015 Facts and Figures. http://www.nhpco.org/sites/default/files/public/Statistics_Research/2015_Facts_Figures.pdf.

Regardless, Medicare expenditures for beneficiaries in the last year of life are about half of what they were about 30 years ago. The emphasis on hospice and palliative care services for patients who are near death appears to be making a significant difference in a more appropriate allocation of health care resources while improving the quality of care. But unfortunately, we still have a long way to go in some areas: (1) Many persons 65 and older (73% of respondents) have not discussed end-of-life care preferences with a physician and 40% have not documented end-of-life wishes. (2) Moreover, two-thirds (68%) of physician respondents report not having been trained to discuss end-of-life care with patients.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

June 24, 2016

Zeke Emanuel May Not Be Right This Time: Increasing Costs Will Probably Not Slow Antibiotic Resistance

Ezekiel J. (Zeke) Emanuel, MD, PhD, is chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania. On May 30, 2016, the Washington Post published an opinion piece by Dr. Emanuel titled “Want to Win $2 Billion? Create the Next Antibiotic.”

In the article, Dr. Emanuel makes two key points: (1) the low cost of antibiotics may be one of the principal factors that have led to doctors over-prescribing these drugs; (2) the low cost of antibiotics with the resulting low rate of return on investment for pharmaceutical companies dis-incentivizes drug manufacturers from allocating more resources for the research and development of new antibiotics to combat evolving “superbugs” (bacteria resistant to current antibiotics). He offers ideas to help solve the problem including: (1) mandating that all hospitals create antibiotic stewardship programs to monitor antibiotic use within institutions; (2) require that all antibiotic prescriptions written be reviewed to assure that the prescribing is warranted according to national guidelines; (3) increasing the charges for antibiotics; and (4) creating a $2 billion prize with additional taxes or surcharges to be awarded to individuals or entities that develop new antibiotics to counter identified microbial threats.

One should be very careful in challenging any suggestions Dr. Emanuel might make – after all he is an internationally recognized health policy and medical ethics expert – but in this case I think he is mistaken about issues and that his ideas may have unintended negative consequences that will make matter worse.

Decades years ago, antibiotics were far more expensive than they are today. Loss of patent protection and generic substitutes have substantially lowered antibiotic costs. But the cost of the antibiotics a few years back had little to do with the development of resistant organisms. One might argue that antibiotics perhaps are far more readily available than is good for man. (One example is farmers using antibiotics to improve their beef cattle and dairy herds.) Antibiotic resistance is as evitable as natural selection; resistance evolves from appropriate and inappropriate use.

Without question, antibiotics are too freely used and are unnecessarily available. The Centers for Disease Control and Prevention has estimated that over half of the outpatient antibiotic prescriptions written are medically unnecessary. Some might suggest that they be available without prescription. If it were safer to use antibiotics without proper provider oversight, certainly they would be marketed as over-the-counter drugs in the US. But with evolving resistance, it is also apparent that antibiotics should be accessible only with better foresight and oversight.

But even if we in the United States were to dramatically curtail antibiotic use by prescribing drugs more appropriately, one should still ask “What about the rest of the world?” The US has 4% of the world’s population. In the US (and more developed countries), we are very concerned about the availability of antibiotics and appropriate use; but most of the world is not. Antibiotics are readily available in Central and South America and Asia and Africa without a prescription. Clearly resistant organisms will continue to evolve in the world whether we decrease the rate of resistance in the US or not. Moreover, the more recent worldwide epidemic health scares have been from viruses – Ebola, Zika, and Chikungunya – for which antibiotics are of no help.

The very best strategy in combating resistant organisms remains prescribing antibiotics appropriately. Successful ideas to help prescribe antibiotics more appropriately have been proposed. Somehow, we need to get providers to practice evidence-based medicine. Of course, we should be doing this in every aspect of providing care, not just in prescribing antibiotics. Our primary ethical obligation as providers is to practice competently. Radical ideas – like increasing the cost of antibiotics, mandating that all hospitals have antibiotic stewardship programs, asking more knowledgeable peers to review every single antibiotic prescription, and taxing Medicare hospitals to create prize money to award successful antibiotic developers – may work; but the formula seems too extreme. If we need peers watching everything that other providers do, is this really the solution that will assure best practice over the long haul?

May 27, 2016

Support New York State’s Oncofertility Legislation

As I have discussed in previous blogs, fertility preservation for cancer patients is very expensive and it is rarely covered by insurance. Cost is the primary barrier for why cancer patients do not preserve their fertility before undergoing lifesaving, yet potentially sterilizing, treatments. One cycle of IVF is on average $12,400 and estimates for ovarian tissue cryopreservation range from $5,000-$30,000. Furthermore, annual storage fees for frozen gametes and embryos can run up to hundreds of dollars a year. For many, especially while in the midst of a life-threatening health emergency, these costs are prohibitive, and future fertility is left to chance.

Legislation, however, is currently being considered in New York State that could change this situation. SB7219, authored by State Senator Diane Savino, would alter the current infertility mandate in New York to include coverage for standard fertility preservation services needed by those facing possible iatrogenic (medically-induced) infertility due to treatments such as chemotherapy, radiation, and surgery.

If you are a resident of New York and care about this issue, please contact your state representative to let them know how important this is for you! By bringing together voices of patients, professionals, and families we can help make this change.

How You Can Get Involved:

If you are a cancer patient, survivor or family member who has been touched by this issue, please submit your email here:

Coalition to Help Families Struggling with Infertility - Link for Individuals

If you are a healthcare provider serving patients in New York who would be positively impacted by this coverage, please submit your email here:

Coalition to Help Families Struggling with Infertility - Link for Family Building Professionals

If your institution or nonprofit organization is interested in joining the Coalition to Help Families Struggling with Infertility, email advocacy@helpfamilieswithinfertility.net.

Time is of the essence! All communications should be submitted by June 2nd if possible; the last day of the NY legislative session is June 16th.

References:

  1. To read the entire Bill: http://legislation.nysenate.gov/pdf/bills/2015/S7219
  2. To learn more about the Bill or the Coalition: Coalition to Help Families Struggling with Infertility Website

 

- See more at: http://www.allianceforfertilitypreservation.org/blog/support-pending-fertility-preservation-legislation-in-new-york#sthash.EjwhZ7wP.dpuf

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

 

August 6, 2015

“Bad Guy” Big Pharma: An Easy Target?

<p style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">Do Americans always need an entire industry to hate or complain about? Big tobacco, big banks, big insurers, big brokerage houses, big oil and energy companies, big automakers, big for-profit hospital companies, big pharma, have all been easy targets in the past. More often than not because of big profits, abuses and excesses, and safety concerns. On July 23, 2015, The New York Times fired another salvo at big pharma when it published Andrew Pollack’s piece titled “<a href="http://www.nytimes.com/2015/07/23/business/drug-companies-pushed-from-far-and-wide-to-explain-high-prices.html">Drug Prices Soar, Prompting Calls for Justification.</a>” The article highlights an issue that has been smoldering off and on for years: how do drug companies arrive at prices for their new products? After reading the article more carefully and thinking about the pressured state legislators who are introducing “drug cost transparency” bills, one may wonder why this issue now? The specific trigger this time may be <a href="http://www.huffingtonpost.com/jeffrey-sachs/the-drug-that-is-bankrupt_b_6692340.html">Gilead Sciences’s Sovaldi</a>® (sofosbuvir).</span></p> <p style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">The New York Times has <a href="http://www.nytimes.com/2015/05/20/business/high-cost-of-hepatitis-c-drug-prompts-a-call-to-void-its-patents.html">written about the costs</a> of this drug before and how it is straining Medicaid budgets. This may be the most likely reason that these state legislators are asking for drug cost transparency now. The <a href="http://www.sacbee.com/news/politics-government/article7058828.html">costs of the hepatitis C cure</a> for affected California Medi-Cal patients alone would equal the total education budget for the state.</p> <p><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;"><strong>The Alden March Bioethics Institute offers a Master of Science in Bioethics, a</strong> </span><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="http://www.amc.edu/Academic/bioethics/index.cfm">website</a>.</strong></p>
May 3, 2015

“Reasonable Profits” For Pharmaceutical Manufacturers?

<p class="MsoNormal" style="line-height:200%"><span style="line-height: 200%; font-size: 11.1999998092651px;">With the recent success of the blockbuster drug Sovaldi© (Gilead Sciences, Inc.), the manufacturer’s <a href="https://www.google.com/#q=gilead+sciences+stock+price">stock price</a> has quintupled in the last four years. </span><span style="line-height: 200%; font-size: 11.1999998092651px;">This supports the views of some that pharmaceutical prices in America should be subject to <a href="http://www.nytimes.com/2015/04/28/us/obama-proposes-that-medicare-be-given-the-right-to-negotiate-the-cost-of-drugs.html">greater government scrutiny</a> and controls like other industrialized countries.</span></p> <p class="MsoNormal" style="line-height:200%"><span style="line-height: 200%; font-size: 11.1999998092651px;">High profits within the pharmaceutical industry are nothing new. “Historically [before the recent recession], the drug industry in America has been the </span><a style="line-height: 200%; font-size: 11.1999998092651px;" href="http://www.cluteinstitute.com/ojs/index.php/JBER/article/view/2640">top performing</a><span style="line-height: 200%; font-size: 11.1999998092651px;"> [sector] in terms of return on revenues (average 18.6%) and return on assets (average 17.7%) compared to 4.9% and 3.9% respectively for median companies in the Fortune 500 industries.” </span></p> <p class="MsoNormal" style="line-height:200%"><span style="line-height: 200%; font-size: 11.1999998092651px;">The <a href="http://www.pnhp.org/sites/default/files/docs/2011/Biosocieties_2011_Myths_of_High_Drug_Research_Costs.pdf">extremely high costs</a> of drug research and development (R&amp;D) are often cited as the principal rationale for allowing an above average return and minimizing government price controls. </span><span style="line-height: 200%; font-size: 11.1999998092651px;">However, studies have shown that “[as t]o the question of whether pharmaceutical drugs costs are justified by R&amp;D, the answer is no. Pharmaceutical firms do indeed invest money in R&amp;D, as do other production and service firms, but this investment <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1536-7150.2011.00820.x/abstract">does not account for</a> their large ongoing profit, which ranges from 2.5 to 37 times the non-pharmaceutical industry average over time.”</span></p> <p class="MsoNormal" style="line-height:200%"><span style="line-height: 200%; font-size: 11.1999998092651px;"><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;"> </span></span></p>
March 12, 2015

The Unique Challenge of Healthcare Reform in the US, and Why it Might All Fall Apart

<p class="MsoNormal" style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">Those of us who aspire to eventually having an affordable, quality, accessible healthcare system for all citizens, or even for most citizens, must first face an obvious but under-discussed challenge that uniquely American: The major players in the US healthcare system—including private insurance companies, pharmaceutical companies, medical device and equipment makers, medical specialties and sub-specialties, healthcare organizations and their executives and shareholders, and all of their lobbyists—are motivated by their own economic self-interests first and foremost. Which means our aspirations must be viewed as a long-term struggle.</span></p> <p class="MsoNormal" style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;">Healthcare in American is simply unfettered capitalism at work. Let me hasten to add, this is not to say that all of these entities don’t do some remarkable work—I owe my life to the U.S. healthcare system as do millions more. But the fact remains that much of the extravagantly high costs of medical care in the U.S. healthcare system has nothing to do with improving or adding quality care for patients and producing good outcomes. Rather it’s a reflection of how these key players pursue their own entrenched financial interests, while creating narratives to the public that the services they provide is essential for quality healthcare. Interestingly, over time, this bloated, inefficient system has been generally accepted by the public and therefore gained a façade of legitimacy that makes it virtually intractable to reform.</span></p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; line-height: 19.0400009155273px; font-size: 12px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; line-height: 19.0400009155273px; font-size: 12px;"> </span></p>
March 4, 2015

Will the US Ever Control Drug Prices Like the Rest of the World?

<p class="MsoNormal" style="font-size: 11.1999998092651px; line-height: 19.0400009155273px;"><span style="line-height: 22.3999996185303px; font-size: 11.1999998092651px;">Probably not. It’s just not the <a href="http://www.nytimes.com/1991/05/24/business/why-drugs-cost-more-in-us.html">American way</a>.</span></p> <p class="MsoNormal" style="font-size: 11.1999998092651px; line-height: 22.3999996185303px;">And, it is true that <a href="http://www.ncbi.nlm.nih.gov/pubmed/22392823">Americans pay more</a> out-of-pocket for prescription drugs than citizens in other developed countries. Other nations use <a href="http://lawdigitalcommons.bc.edu/iclr/vol26/iss2/8/">government cost controls</a> and aggressive cost containment strategies to regulate prescription drug costs. Historically, the US Congress has deliberately and consistently <a href="http://www.amazon.com/Taking-Your-Medicine-Regulation-United/dp/0674867254">refused to regulate</a> prescription drug pricing directly.</p> <p class="MsoNormal" style="font-size: 11.1999998092651px; line-height: 22.3999996185303px;">The American pharmaceutical industry often has been accused of gouging consumers and profiteering. Its investor return on equity is <a href="http://www.bbc.com/news/business-28212223">usually much higher</a> than other industries. And prescription <a href="https://host1.medcohealth.com/art/pdf/kap19Medications.pdf">drug pricing differentials</a> have always been difficult to understand, whether at the local pharmacy or within similar hospitals in the same locale.</p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="http://www.amc.edu/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;"> </span></p>
January 19, 2015

Why Buying A Car Is So Unlike Buying Healthcare

<p style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">Let’s say you are looking to buy a car. You think you might want to buy a Volvo so you go down to the Volvo dealer and check out the new models. But you are shocked by what you see. You realize that you really don’t need to spend $35 to $40,000, or more, on a new car, so you decide to visit the Subaru dealer. There you find very nice alternative models for thousands of dollars less. You are delighted to have a new Outback for about $27,000.</span></p> <p class="MsoNormal" style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">The above story is how private markets and market choices work for the vast majority of items that we purchase to meet most of our needs as human beings. However, it has become painfully obvious that healthcare is an area where the normal model of markets and market choices do not apply. I’ll use a personal example.</span></p> <p><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="color: #000099; text-decoration: underline;" href="/Academic/bioethics/index.cfm">website</a>.</strong><span style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 19.0400009155273px;"> </span></p>
September 25, 2014

As Doctors Lose Clout, Drug Firms Redirect the Sales Call

[The Wall Street Journal] SAN DIEGO—Kendall French used to pitch drugs to doctors who could prescribe them. But many of those doctors now work for hospitals that don’t give them final say over what is on the menu of medicines they can pick. So when the GlaxoSmithKline PLC saleswoman began plugging two new lung-disease drugs […]
September 16, 2014

Is It Possible To Do Bioethics In Contemporary America?

<p style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">Ok, I realize I am being somewhat provocative. But there is a real and very serious issue, which I am groping to address in a more precise manner.</span></p> <p class="MsoNormal" style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">In my last blog I described the contemporary moral setting from a philosophical perspective as one in which no single substantive normative moral perspective can resolve moral questions, such as the boundaries of human life and the scope of individual rights, with final moral authority. This is just to say, more simply and obviously when we reflect upon it, that in democratic, secular America, ethics, both philosophically and practically, becomes inextricably linked to public discourse in politics and public policy.</span></p> <p class="MsoNormal" style="line-height: 19.0400009155273px;"><span style="line-height: 19.0400009155273px;">When bioethicists ask questions and make arguments about abortion, physician assisted suicide, stem cell research and cloning, and many other similar issues that pertain to questions about the value of human life in relation to both individual rights and societal goals, we have no privileged moral authority from which to draw. As bioethicists we engage in procedural, persuasive discourse, based on conventional moral principles that most often conflict, which is why there is moral dilemma or problem requiring analysis and prioritization. Our purpose in defending a particular moral position is to win assent from others. In short, for a bioethicist to promote a moral position, it is implicitly an attempt to build a consensus among readers and listeners that will hopefully impact public opinion about a particular moral problem or question. Moreover, to the extent these questions have public policy ramifications, and practically all do, it means that moral discourse is also oriented to effect change and function as a medium in which bioethicists often speak as advocates about how moral options should be framed as public policy positions in a democratic society.</span><span style="line-height: 19.0400009155273px;"> </span></p> <p class="MsoNormal" style="line-height: 19.0400009155273px;"><strong style="color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px; line-height: 20px;">The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our <a style="text-decoration: underline; color: #000099;" href="/Academic/bioethics/index.cfm">website</a>.</strong><span style="line-height: 19.0400009155273px; color: #34405b; font-family: Arial, Helvetica, sans-serif; font-size: 12px;"> </span></p>

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