Opioids: Where Your Doctor Is Trained Impacts What He/She Prescribes for You

A new study by economists at Princeton University shows that where a doctor is trained effects the prescriptions he or she writes.

The study focused on opioids, and differences in prescription-writing between graduates of top and bottom-ranked medical schools. Key findings:

• Doctors graduating from lower ranked medical schools write a much larger volume of opioid prescriptions than those from top medical schools.

From 2006 to 2014, “If all general practitioners had prescribed like those from the top-ranked school [Harvard], we would have had 56.5% fewer opioid prescriptions and 8.5% fewer overdose deaths,” said Janet M. Currie, the Henry Putnam Professor of Economics and Public Affairs at Princeton’s Woodrow Wilson School of Public and International Affairs. Currie conducted the study with Molly Schnell, a Princeton Ph.D. candidate in economics.(1)

• Doctors who receive additional training in pain management write fewer opioid prescriptions than their peers.
• Doctors trained in the Caribbean write more opioid prescriptions than foreign-born doctors trained elsewhere outside the US.
• More recent medical graduates are writing fewer opioid prescriptions than are older physicians.  That again raises the question of how well some veteran doctors are keeping up with new trends and issues.

A counter-argument is that doctors lack good alternatives to opioids for management of pain.(3) However, according to the Princeton research, many doctors may simply not understand the choices they are making in writing a script or the options that may be available.

Why should the impact of training be limited to opioid prescriptions? Why shouldn’t it impact other treatment and drug choices?

What you need to consider:

The framed degree on your doctor’s wall is more than a decoration. You need to read it. If the degree is from a school with which you are unfamiliar, you need to get a conversation going about what other training he/she has taken. If the answers aren’t suitable, you need to consider finding another doctor.

A list of the top medical schools for primary care is available at

https://www.usnews.com/best-graduate-schools/top-medical-schools/primary-care-rankings

In the 2017 rankings, the top 20 for primary care (there are separate rankings for research, but the focus in this article is on patient care) are (4):

1. University of Washington
2. University of North Carolina – Chapel Hill
3. University of California – San Francisco
4. Oregon Health and Science University
5. University of Michigan
6. University of California – Los Angeles
7. University of Minnesota
8. (tie) Baylor
9. (tie) University of Colorado
10. (tie) University of Pennsylvania
11. (tie) University of Texas, Southwest Medical Center (Dallas)
12. University of California – San Diego
13. University of Pittsburgh
14. (tie) University of Massachusetts – Worchester
15. (tie) University of Wisconsin – Madison
16. Harvard University
17. University of Nebraska
18. (tie) University of California – Davis
19. University of New Mexico
20. East Carolina State University (Brody)

 

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Sources:

1. Molly Schnell, Janet Currie. Addressing the Opioid Epidemic: Is There a Role for Physician Education? NBER, August 2017 DOI: 10.3386/w23645
2. Princeton University, Woodrow Wilson School of Public and International Affairs. “Doctors trained at lowest-ranked medical schools prescribe more opioids.” ScienceDaily. ScienceDaily, 14 August 2017. <www.sciencedaily.com/releases/2017/08/170814134811.htm>
3. Malcolm Thaler, MD, “Why Is Opioid Addiction Happening to So Many of Us?” Live Strong, 29 August 2016. http://www.livestrong.com/article/1012275-opioid-addiction-happening-many-us/?utm_source=aol.com&utm_medium=referral&utm_content=opioid-addiction-happening-many-us&utm_campaign=AOL-Wellness
4. https://www.usnews.com/best-graduate-schools/top-medical-schools/primary-care-rankings

 

Antidepressants, Alzheimer’s and Brain Injuries: making bad worse

What we knew:

• Use of antidepressants with Alzheimer’s patients increases the risk for falls and hip fractures
• There is a protein found in the brain cells of persons with dementia and brain injuries that causes the Axon in the cell (electronic message transmitter) to swell and shut down. This protein is absent from normal cells. Elimination of the protein can cause the axon to start functioning again. (References are in previous blog.)

What the University of Eastern Finland has added to what we know:

• Use of antidepressants with Alzheimer’s patients results in an increased incidence of traumatic brain injuries among these patients

The mechanism for the injury is probably falling. With slower mental processing and thus slower reflexes, these patients are less able to protect themselves when falling. That means a higher rate of concussions.

This ties back to another previous post on this blog — “deprescribing”. Drugs may have a value in one stage of a person’s life and be counterproductive at another stage. Doctors know how to prescribe drugs, but there are few protocols (apart for drug interactions) regarding when to stop taking a drug.  There is a group in Canada developing guidelines for deprescription, and while NIH has published articles on the topic, I’m not aware of any similar projects to develop guidelines in the US. Some US physicians appear to be doing this on an ad hoc basis.

I suspect deprescription is not a popular topic among pharmaceutical executives, but it needs to be addressed. Continuation of unnecessary medication is just one of many factors that bloats medical costs in the US — and why spending level no longer indicates quality of care. Unnecessary medication poses risks to some patients.

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Sources:

1. Heidi Taipale, Marjaana Koponen, Antti Tanskanen, Piia Lavikainen, Reijo Sund, Jari Tiihonen, Sirpa Hartikainen, Anna-Maija Tolppanen. Risk of head and traumatic brain injuries associated with antidepressant use among community-dwelling persons with Alzheimer’s disease: a nationwide matched cohort study. Alzheimer’s Research & Therapy, 2017; 9 (1) DOI: 10.1186/s13195-017-0285-3
2. University of Eastern Finland. “Antidepressant use increases risk of head injuries among persons with Alzheimer’s disease.” ScienceDaily. ScienceDaily, 9 August 2017. <www.sciencedaily.com/releases/2017/08/170809073627.htm>.
3. Gurusamy Sivagnanam, “Deprescription: The prescription metabolism,”
   J Pharmacol Pharmacother. 2016 Jul-Sep; 7(3): 133–137.

   doi:  10.4103/0976-500X.189680
4. http://deprescribing.org/
5. http://www.drjohnm.org/2014/10/to-deprescribe-adding-a-new-verb-to-the-language-of-doctoring/
6. Joaquín Hortal Carmon, IvánAguilar Cruz, FranciscoParrilla Ruiz, “A prudent deprescription model,” Science Direct, Medicina Clínica, Volume 144, Issue 8, 20 April 2015, Pages 362-369.

 

Drug Profits in the US: Who Gets What?

Conflicts-of-interest in the distribution of prescription drugs are driving health insurance costs higher in the US.

The Wall Street Journal analysis uses the example of the EpiPen, a drug used to counter life-threatening allergic reactions.

The example illustrates two points about prescription drug distribution in the US:

• Who the players are
• How the system misfires

The bottom line is that many consumers are being incentivized to use the more expensive brand name product rather than much less expensive generic version. Insurers are eating the costs of the brand name version, which in turn shows up in insurance rates for the following year.

To be clear, this is the private sector misfiring on its own, with tacit permission from Congress.

Pharmaceutical distribution in the US involves six players. The profit percentages are based on the EpiPen example and will vary for  other drugs and insurance plans. In that example, at a list price of $300, the actual money changing hands with insurance is $220. (The consumer without insurance is out the full $300, but that’s another issue.)

• The consumer who buys the drug ($35 out of pocket)
• The plan sponsor or insurer who pays much of the cost of the drug ($185)
• The pharmacy, which earns 7% on the drug (in this case, $16)
• A wholesaler, which may take a 1% profit on the drug ($3)
• The drugmaker (62% or $137)
• The pharmacy benefit manager (PBM, 8% or $18)

(The numbers are approximately and don’t add up because of other markups, discounts and rebates involved in the prescription process.)

The benefit manager is the player with which most consumers are unfamiliar. His/her job is to design benefit plans and negotiate discounts and rebates with drugmakers that are distributed to pharmacies and wholesalers.

The benefit manager is potentially subject to a conflict of interest. In the EpiPen case, the Journal asserts that the benefit manager receives a higher fee for designing plans that promote the use of the more expensive brand name drug. Thus a plan may

1. Feature the same out of pocket cost (copay) to the consumer for the brand name as for the generic, even though the actual cost of the two is quite different; or
2. Offer a lower copay for the brand name.

An attentive pharmacist will recommend that the consumer buy whatever is less expensive — the pharmacist has no direct concern with what the insurer pays, and may not in fact know. CVS, for example, does not provide that information it its staff.

This isn’t the first time that analysts have flagged conflicts of interest with PBMs. The issue has arisen previously with regard to

• Major pharmacy chains having in-house PBMs
• PBMs owning mail order pharmacies.

In both cases, the PBM has an interest in maximizing its own revenue rather than minimizing costs to insurers, plan sponsors or consumers.

How can this happen? Pretty easily actually, if the plan sponsor or insurer is inattentive to what the benefit manager is doing.  With the myriad of drugs on the market, this inattention is understandable if not excusable.

Interesting question: Who’s better at policing drug prices — traditional insurers or large companies running self-insured drug plans? Or is there a different?

What you need to consider:

1. As a consumer, it’s in your interest to buy generic drugs even if the brand name has the same copay — if the brand name and copay are equally effective. Someone is paying the higher price for the brand name, and that extra cost will show up in insurance rate increases in your future.
2. Drug companies may offer coupons for both brand name and generic products, but may only distribute the coupons for the brand name. You may have to ask to get the coupon for the generic.
3. You always need to ask the pharmacist if a generic is available for any brand name prescription. Ignorance can hurt you.

 

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Sources:

1. Jonathan Rockoff, “Behind the Push for High-Price EpiPen,” The Wall Street Journal, 7 August 2017, page B3.
2. Applied Policy, “Concerns Regarding the Pharmacy Benefit Management Industry,” November 2015. http://www.ncpa.co/pdf/applied-policy-issue-brief.pdf
3. Brian Friedman, “Big pharmacies are dismantling the industry that keeps US drug costs even sort-of under control,” Quartz, 17 March 2016. https://qz.com/636823/big-pharmacies-are-dismantling-the-industry-that-keeps-us-drug-costs-even-sort-of-under-control/
4. http://www.pbmwatch.com/conflicts-of-interest.html

Diabetes: Best and Worst States

Diabetes is huge problem both for its direct affects as well as its ability to weaken the body’s defenses against other disease.

Diabetes can be genetic (Type 1) but the bulk of the problem is self-inflicted (Type 2) — a function of diet, obesity and lack of exercise. That’s reflected in the areas of the country in which it is most and least prevalent.

One issue with diabetes numbers is that an estimated 50% of those with diabetes don’t know it. Testing requires testing blood glucose levels after fasting, and a lot of people simply don’t see their doctors regularly, if they have a doctor at all.

Overall, the known incidence of diabetes in the US ranges from 6.8% in Colorado to 16.5% in Puerto Rico.

The worst areas in the US are mostly in the Old South

• Puerto Rico, 16.5%
• Mississippi, 14.7%
• West Virginia, 14.5%
• Alabama, 13.7%
• Kentucky, 13.5%
• Louisiana, 12.7%
• Tennessee, 12.7%

The rates in some of these Southern states may be much higher than what’s documented, due to relatively poor provision and use of healthcare services in places like Mississippi, West Virginia and Kentucky.

The areas with the lowest rate of diabetes are

• Colorado, 6.8%
• Utah, 7.0%
• Alaska, 7.6%
• Minnesota, 7.6%
• Montana, 7.9%
• New Hampshire, 8.1%
• Vermont 8.2%

These are areas in which people spend a lot of time outdoors and active.

As with smoking, poverty is linked to diabetes. Relatively affluent states like New York, New Jersey and Connecticut have rates that are below 10% despite the predominance of office-based work.

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Sources:

1. http://www.benefitspro.com/2017/08/03/5-worst-states-for-diabetes?kw=5+worst+states+for+diabetes&et=editorial&bu=BenefitsPRO&cn=20170804&src=EMC-Email_editorial&pt=Daily&page=3

ACA, Next Act

Karma in politics?

The states that are getting shafted by extreme increases in health insurance costs for 2018 are the ones that voted for Trump last year.

The Wall Street Journal identifies five states in which insurers are asking for rate increases that are close to or higher than 30% for 2018. These are

• Idaho
• West Virginia
• South Carolina
• Iowa and
• Wyoming

These aren’t wealthy states, and that increase is going to make health insurance unaffordable for many residents.

In turn, that will put the uninsured back into receiving medical care in emergency rooms. Hospitals add the cost of ER care for the uninsured to the bills of other patients, which means that hospital charges (and group health rates) will increase for everyone else.

Some states have avoided this, notably New York and Pennsylvania. It might be instructive to compare what the administrations in those states have done differently. I suppose it’s coincidental that the states avoiding huge rate increases have Democrats as governor?

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Sources:

1. “Some Insurers Seek ACA Premium Increases of 30% and Higher,” The Wall Street Journal, published online, 1 August 2017, 8:45PM.

Access to Health Services

The US doesn’t provide equal access to health services.

That’s not up for debate. The Centers for Medicare and Medicaid Services has created a set of interactive charts showing who has access and who doesn’t.

The example below is for home health services. Basically, nursing homes/rehab facilities are expensive. The average cost of nursing home care is $9,200 per month. That’s  more than many families can afford. That’s especially true for seniors, as Medicare only covers the first 100 days of nursing home care. The rest is the responsibility of the patient.

The viable alternative to nursing home care is home care, but families sometimes require assistance from trained professionals in providing this care. At $3,600 per month, that’s a lot less than a nursing home, although still not cheap.

Unfortunately, a skilled facility isn’t always available.

The map shows the average number of home health care providers per county.

• Certain states are well provisioned: Arizona, California, Connecticut, Florida, Illinois, Massachusetts, Michigan, Nevada,, Ohio, Oklahoma, Texas and Utah.
• Certain states aren’t: Arkansas, Iowa, Kentucky, Mississippi Montana, North Dakota, South Dakota, West Virginia and Wyoming.

When we look in detail at the better served states, we see that services are primarily in urban areas. Smaller towns and rural areas are poorly served. The examples of Illinois and Texas are shown below. In Illinois, services are concentrated around Chicago and the St. Louis suburbs. In Texas, the concentrations are around Dallas, Austin and Houston. West Texas is relatively poorly served.

(Sorry about the chart titles: that’s a problem with the jpeg download from the CMS site. The titles are supposed to read “Home Health — Average number of providers per county”)

Why don’t voters hold their politicians accountable for the lack of services?

For that matter, since Mississippi and West Virginia are at the rock bottom on almost every measure of quality of life, why does anyone live there?

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Sources:

1. https://data.cms.gov/market-saturation

A Grim Reminder of the Link Between Heart, Lungs and Brain

Cerebral hypoxia is the medical term for an inadequate supply of oxygen to the brain. Brain cells can begin to die within 5 minutes of a cut-off or severe reduction of oxygen supply.

It’s a surprisingly common problem. That’s in part because of the variety of conditions that can cause oxygen deprivation. While oxygen deprivation (vascular dementia) is a more common cause of dementia among seniors than is Alzheimer’s, the condition isn’t limited to old age.

The BBC reports today that a 20-year old soccer player collapsed from brain damage after developing a heart arrhythmia during a friendly match played in Austria.(1) The brain damage appears to be severe and permanent.

Other causes for cerebral hypoxia include:

• COPD or severe asthma
• Drowning
• Strangling/choking/suffocation
• Cardiac arrest
• Head trauma
• Carbon monoxide poisoning
• Complications of general anesthesia
• Hyperventilation
• Consistent work in a nitrogen rich environment

Very low blood pressure can be a factor as well. That can result from medication, certain foods, frequent coughing (from congestion or allergies) and alcohol, and especially a combination of these factors.

Symptoms of hypoxia include

• Difficulty with complex tasks
• Poor short-term memory capacity
• Decreased motor control
• Cyanosis (bluish tone) of the skin
• Increased heart rate
• Fainting

The impact of cerebral hypoxia depends largely on whether the victim loses consciousness and for how long that occurs.  According to NIH,

During recovery, psychological and neurological abnormalities such as amnesia, personality regression, hallucinations, memory loss, and muscle spasms and twitches may appear, persist, and then resolve.(2)

However, it may take days or weeks before the full extent of damage from carbon monoxide poisoning becomes evident. Since carbon monoxide is odorless, that’s why monitors are so essential in the home. A simple act such as stacking boxes too close to a furnace can fill a home with this deadly gas.

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Sources:

1. BBC News, “Abdelhak Nouri: Ajax player suffers brain damage after collapse”
2. NIH, “Cerebral Hypoxia Information Page.” https://www.ninds.nih.gov/Disorders/All-Disorders/Cerebral-Hypoxia-Information-Page
3. Dementia.org, “Oxygen Deprivation Associated With Onset Of Dementia.” https://www.dementia.org/oxygen-deprivation-dementia