Fixing the Pharms

Whether you love or loathe pharmaceutical companies, it's clear that we have a problem with pharmaceutical delivery in the U.S.

First of all, some drugs are inexplicably expensive. There's the $93,000 prostrate cancer drug Provenge, for example,  which I've blogged about in the past ("The Skewed Values of Drug Prices"). A more recent example is Anascorp, an orphan drug (used to treat rare diseases) approved by the FDA in August to treat scorpion stings. Anascorp has been used in Mexico for many years, at a cost of $100 per dose, but in the U.S. it now costs  $12,000 per dose, according to a recent Kaiser Health News blog post on the topic ("Treating a Scorpion Sting: $100 in Mexico or $12,000 in U.S."). Blog author Jenny Gold points out that patients need up to five doses of the anti-venom to recover.

It's not fair, however, to blame the cost entirely on the manufacturer, Rare Disease Therapeutics. Gold writes that hospitals in Arizona purchase Anascorp for about $3,700 per dose, then mark up the price to cover their own costs, including the cost of providing care for uninsured patients. It's a long and tangled journey from a $100 dose to a $12,000 dose, and one that does not serve patients well.

More common drugs aren't faring much better, however. There is currently a shortage of generic injectable drugs used to treat cancer and other serious medical problems, an issue covered earlier this month by another Kaiser Health News blog post ("Drug Shortages Affect More Than half a Million Cancer Patients").

The problem has become so acute that it triggered a presidential smackdown, a.k.a. an executive order, in October that demands FDA action and includes Justice Department investigations of possible price gouging.  There are many reasons for these drug shortages, such as a shortage of raw materials needed to make the drugs, and a limited number of manufacturers, who drop production of the drugs if they are not profitable enough or if they have problems with the manufacturing process (as sometimes happens with vaccines).

What's the cure for all this? Don't get sick, silly. But failing that, as we all do from time to time, it seems clear to me that the government needs to flex its muscle with the pharmaceutical companies that bring both great good and great expense to health care.

Taxpayer-funded research should not lead to drugs that taxpayers cannot afford when they need them. The pursuit of blockbuster drugs - those that earn $1 billion or more per year in revenues -  should not undermine the development of less profitable, equally necessary treatments for other diseases. Government incentives and regulations should ensure that a wide range of manufacturers are providing the medications that Americans need.

What vaccines say about parents

Two vaccines targeted to children have been in the news this month: a vaccine in clinical trials in parts of Africa that offers some protection from malaria (which is a leading cause of death in African children, according to the World Health Organization), and the human papillomavirus (HPV) vaccine, which prevents infection with certain cancer-causing strains of the HPV virus. Although the HPV vaccine has been recommended for tween girls for several years, the CDC will likely recommend it for boys as well soon.

Each of these vaccines is quite unique. The malaria vaccine, if approved, would be the only vaccine that prevents a parasitic infection (all other vaccines prevent infection with certain viruses or bacteria). The HPV vaccine is one of only two vaccines that can prevent cancer (the other one is the Hepatitis B vaccine, which prevents infection with a virus that can cause liver cancer). Until recently, the HPV vaccine was the only childhood vaccine recommended only for girls, not boys, because HPV infections can cause cervical cancer.

The malaria vaccine, which is only about 35% effective in preventing malaria, is being heralded as a major breakthrough in preventing a disease that can be deadly in children, especially as the mosquitoes that transmit malaria become resistant to pesticides. On the other hand, the HPV vaccine, which prevents infection with certain strains of HPV that can cause serious health problems such as cervical cancer, genital warts, and oral cancers, has triggered a lot of angst and hand-wringing. It has been criticized as a pharmaceutical boondoggle (costing about $400 for the three-dose series), an invitation to promiscuity for the tweens who receive the vaccine, or (when the vaccine is mandated), a governmental intrusion in the lives of people.

Malaria is transmitted by mosquitoes, while HPV is generally transmitted by sexual contact, which is part of the reason some Americans are squeamish about the HPV vaccine. Vaccines are a public health initiative, though, and American parents tend to forget this as they fret about whether a vaccine will reset their child's moral compass.

Although many parents view vaccines as an individual choice that affects only their family, a vaccine doesn't just protect one child from an infection. Most vaccines also prevent the child from transmitting an infectious disease to someone else. Others might be vulnerable to a disease because they are unvaccinated, too young to be vaccinated, have an illness that prevents them from getting a vaccination, or because (often unknown to them) they have not developed immunity to a disease after being vaccinated.

The HPV vaccine recommendation was extended to boys because they also transmit the virus, even if they are generally at less risk for developing cancer from the virus than girls are. It can be hard, though, to persuade parents to think about their neighbor's children as well as their own.

Ignoring Long Term Care

In print and screen advertisements, retirement is often portrayed as a time to start a second career, spend more time with the grandchildren, volunteer for a worthy cause, or travel around the world. Any health problems can be managed with prescription medications and moderate exercise.

Realistically, however, many Americans will ultimately need long-term care in a nursing home or in their own homes when they get older. Medicare, which in most cases does not cover long term care, predicts that 12 million elderly will need long term care by 2020, and HHS predicts that 40% of 65-year-olds will ultimately go into a nursing home for some period of time. Non-skilled long term care is often provided by family and friends, such as help with daily activities, while skilled long-term care often must be paid out of pocket.

With the recent demise of the CLASS Act, a section of health care reform designed to encourage Americans to purchase long-term care insurance, the issue of long term care has come to the forefront. The CLASS Act had fiscal flaws, with high monthly costs for insurance, but dropping it does not solve the problem of long-term care. In this economy, with many families struggling, few want to contemplate the stress and expense of caring for an ill spouse or relative. But ultimately, many of us will need to help out.

Kaiser Health News' Howard Gleckman suggests providing long-term care in the future through universal coverage or through insurance policy incentives. Whatever the solution, the current gaps promise to cause many problems for families as the large generation of Baby Boomers ages, along with the rest of us.

Did You Feel It?

I thought it was a truck going by, but that's what I always think when the little earthquakes strike. It took me a moment to realize what it might be. It was near the end of the work day for me, but my laptop was still on, so I logged on to the U.S. Geological Survey site to find out that it was a magnitude 3.3 earthquake near Oakland, CA yesterday. I was far enough away that I barely felt it.

I reported it on the USGS "Did You Feel It?" page, adding my data to everyone else's, not just because I've been studying statistics lately but because it's exciting to make even a small contribution to science. I showed a printout of responses to my children later and they were interested, too; one of them had felt the earthquake, the other had not.

The USGS site shows math and science in action, data gathered and maps produced for the public good. It's much more interesting to see concepts applied than to, say, memorize the times table. Science that you can feel, hear, and touch is fun to learn, and Americans definitely need to learn more science (perhaps starting with Republican presidential candidate Michele Bachmann and her misguided comments on HPV vaccination).

I wanted to thank the USGS for making science fun and relevant yesterday. Did I feel it? Yes - surprise and excitement and a twinge of worry as the earthquake passed through and I looked up its magnitude online. Did my kids feel it? Yes - surprise and excitement as they realized that science had just rattled their world a little.

Should Smokers Be Banned from Hospital Jobs?

Texas' Baylor Health Care joined the Cleveland Clinic and other hospitals in banning smokers from hospital jobs, Fierce Healthcare reported today. As Alice Wolke of My FOX Houston explained in an article about Baylor Health Care's decision, "on the company's Careers page, the rules are laid out:

• Applicants who admit to nicotine use will not have their applications processed
• Anyone who is hired will be tested for nicotine
• If you test positive, your job offer will be withdrawn
• After a positive result, you can reapply for the job after 90 days"

By enforcing this policy, Baylor might be setting a healthy example for patients at its hospitals. To be ruthlessly practical, barring smokers from employment also saves the hospital system a lot of money in employee health care costs. The CDC's Vital Signs public heath site is featuring adult smoking statistics this month, and the numbers are statistics they quote are disturbing: the 19.3% of American adults who smoke (as of 2010) create $96 billion yearly in medical costs.

Barring employment to people with certain medical risks or conditions, however, sets a disturbing precedent. Some people argue that these methods are intrusive of medical privacy, especially considering the high levels of chronic disease and other health problems in America. Others point out a certain hypocrisy in targeting employees who smoke while ignoring those who drink heavily or make other risky health choices when they are not at work.

This month, the Department of Health and Human Services is taking a less punitive approach to better health, launching the "Million Hearts" Initiative to prevent one million strokes and heart attacks between now and 2016. Focusing on "proven, effective, inexpensive interventions" that can prevent heart disease and stroke, the initiative includes many stop-smoking measures, such as:

• Providing Medicare funding for stop-smoking medications
• Funding mass media anti-smoking campaigns
• Creating smoke-free (not smoker-free) workplaces
• Possibly reimbursing health care providers better for preventative care such as stop-smoking counseling.

Yes, it's time to reduce the shockingly high number of Americans who smoke. But I think it's more effective to use a carrot than a stick.

Rethinking Children's Hospital Ratings

A study published recently in Pediatrics cited the "statistical uncertainty" of using mortality rates in children's hospitals to rank their quality. The study of approximately 473,000 U.S. patients discharged from children's hospitals in 2008 found that adjusted mortality rates at the 42 hospitals studied did not vary much by the hospital's ranking ("Statistical Uncertainty of Mortality Rates and Rankings for Children's Hospitals").

In a cogent Reuters article on the topic, Frederik Joelving points out that death rates, " which carry heavy weight in commercial rankings like the U.S. News & World Report Best Hospitals, are mostly indistinguishable from a statistical point of view" ("Hospital ratings for kids a roll of the dice: study").

Dr. Chris Feudtner, lead author on the Pediatrics article, told Reuters that when patients look for a hospital, along with rankings they should also consider other issues, such as its proximity to their home. Statistics seem to promise clear answers to complicated questions, but sometimes they can't deliver that.