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

Life Planning Fail

In preparing for battle I have always found that plans are useless, but planning is indispensable. Dwight D. Eisenhower

Life happens, but that’s no excuse for not knowing where you want to go. That’s a particular issue in healthcare.

People don’t like to think about negative events that are going to happen in the future. They’ll still happen, just the same. For Americans, the difference between life expectancy and “healthy life expectancy” is nine years.  They won’t necessarily come as a block toward the end of life. If fact, you don’t know when they’ll come.

A new study points out that people are often faced with making snap decisions about healthcare without adequate information. (1) That’s due to the failure to anticipate something that’s actually rather likely to happen.

People get hurt and sick. The roughly 320 million Americans generated 130.4 million visits to Emergency Rooms in 2016.(3) What are the odds you’re going to need one?

If you don’t know where you want to go in an emergency, you may get stuck someplace you don’t want to be.

Even if you’ve never had an illness in your life, you will. Nothing on this planet is immortal.

Like it or not, here are some questions for which you need to have answers.

• Financial
  • How do I cover sudden and potentially large medical bills? What does my insurance not cover that I’m going to have to pay?
  • How do I cover normal bills if I’m out of work for a few months? Or longer?
• Medical
  • In an emergency, where do I want to go for care? (Related: is my doctor affiliated with where I want to go?)
  • If I’m hurt and need rehab therapy, where do I want to go for care?
  • Does someone have access to my Living Will if I can’t speak for myself? (Having one isn’t a question.)
  • Who will advocate for me with medical personnel if I can’t speak for myself?
• Living
  • Whose going to care for me if (temporarily or permanently) I can’t care for myself?

Seriously, this matters. We have several local hospitals, two of which are problems.

• The ER department at one of them has misdiagnosed my wife twice out of two visits. That’s a 100% rate of being wrong. Do we want to test them a third time?
• The nurses at another consistently ignore a severe allergy that causes anaphylatic shock. Breathing is really nice, but you don’t really appreciate it until you can’t do it. It turns out, the nurses don’t pay attention to wristbands. (One nurse at that facility told us that they assume the allergy bands refer to drugs and not to more mundane and potentially lethal issues like iodine and latex allergies.) Going to that facility is like going to a casino. You might get fixed and you might die. How lucky are you?

As you age, where you go matters more. With seniors, for example, if taken to an ER for a serious fall, there’s a 50% chance of additional problems within six months of the initial injury, including death. Some of that risk is the result of decisions doctors make about medication.(4)

There’s no need to overthink this. Do your homework, ask questions, make decisions, and then get on with the rest of your life. Just get it done.

Aristotle was  right. Anything taken to excess turns bad. That includes both planning and lack of planning.

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Sources:

1. Emily A. Gadbois, Denise A. Tyler, Vincent Mor. Selecting a Skilled Nursing Facility for Postacute Care: Individual and Family Perspectives. Journal of the American Geriatrics Society, 2017; DOI: 10.1111/jgs.14988
2. American Geriatrics Society. “Hospitalized older adults may need more help selecting skilled nursing facilities.” ScienceDaily. ScienceDaily, 7 July 2017. <www.sciencedaily.com/releases/2017/07/170707211128.htm>.
3. Centers for Disease Control and Prevention, “Emergency Department Visits.” https://www.cdc.gov/nchs/fastats/emergency-department.htm
4. Jiraporn Sri-on, Gregory P. Tirrell, Jonathan F. Bean, Lewis A. Lipsitz, Shan W. Liu. Revisit, Subsequent Hospitalization, Recurrent Fall, and Death Within 6 Months After a Fall Among Elderly Emergency Department Patients. Annals of Emergency Medicine, 2017; DOI: 10.1016/j.annemergmed.2017.05.023

Air Pollution and Life Expectancy

A new study led by Prof. Mikael Skou Andersen of Aarhus University in Denmark finds that an increase of 10 micrograms per cubic meter in air pollution reduces an individual’s life expectancy by between 9 and 11 years. This is more than previously thought, although there is a debate about the “economic value” of those years.(1)

“Economic value” translates into an estimate of the amount of spending that is economically justified to reduce air pollution.  While life itself might have infinite value, no one wants to spend infinite money to preserve it. So we try to define how much money value there is in living to 90 as opposed to dying at 79. Under the theory, spending less than that money value to reduce air pollution is justified; spending more isn’t.

The challenge is that the European Union has set standards for air pollution reduction that some of its members are going to have difficulty meeting.

Needless to say, the European standards are more stringent than those in the US.

US rules:  The US has standards for two types of particulate matter air pollution:

• PM₁₀ : inhalable particles, with diameters that are generally 10 micrometers and smaller. Maximum of 150 micrograms per cubic meter of air in any 24 hour period. This may be exceeded once per year on average over a three year period.
• PM_2.5 : fine inhalable particles, with diameters that are generally 2.5 micrometers and smaller.(2) While the goal is 12 micrograms per cubic meter of air, there may be readings of up to 35 micrograms per cubic meter in any 24 hour period.(3)

European rules:

• PM₁₀: 40 micrograms per cubic meter of air, although there may be readings of up to 50 micrograms in any 24 hour period.
• PM_2.5 : 25 micrograms per cubic meter, no exceptions.

The difference in standards between the US and Europe exceeds the amount required to reduce life expectancy in Professor Andersen’s study. Life expectancy is greater in Europe than in the US. The residents of Monaco have a life expectancy that exceeds everyone else on Earth, and exceeds the US by more than 10 years.

What is 10 years of your life worth to you? Air pollution is yet another factor inflating US healthcare costs and the costs of your health insurance.

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Sources:

1. Mikael Skou Andersen. Co-benefits of climate mitigation: Counting statistical lives or life-years? Ecological Indicators, 2017; 79: 11 DOI: 10.1016/j.ecolind.2017.03.051
2. US Environmental Protection Agency, “Particulate Matter Pollution.” https://www.epa.gov/pm-pollution/particulate-matter-pm-basics
3. US EPA, “NAAQS Table.” https://www.epa.gov/criteria-air-pollutants/naaqs-table
4. European Commission, “Air Quality Standards.” http://ec.europa.eu/environment/air/quality/standards.htm

NJ Politics

Arrogance knows no limits.

We have a shutdown of state government for the July 4th weekend in NJ, courtesy of Governor Krispie (Christie) Cream.  Highlights include the closing of state parks and beaches for the weekend for everyone EXCEPT the governor, who is enjoying the holiday in the closed-to-the-public Island Beach State Park.

Why the closing?

The governor eliminated a surtax on high income individuals at the beginning of his first term in office, creating a budget crisis. He failed to find revenue to cover the gap created by the cancelled tax.

His current proposal calls for a special tax on the state Blue Cross and Blue Shield health insurance provider to cover that gap. The insurer will of course pass that tax on to policy holders — basically a back door tax increase.

In the absence of a budget resolution agreeing to his plan, Christie shut the state government.

My hypothesis about his thinking: since health insurance rates are going to climb due to Trump, consumers might not notice a modest additional increase due to Christie. He could bury his increase in Trump’s, and blame someone else.

He wants to blame the shutdown on the Democrats for not going along with his plan. In fact, most people are correctly blaming him. As one blogger wrote, Christie might end his term in November with a popularity rating of less than 10%. His Lieutenant Governor is running to replace Christie this fall; he’s killing her chances of winning.

Gov. Christie Cream — what a piece of work.

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Sources:

1. Tom Davis, “N.J. Government Shutdown Continues As Christie Faces Backlash,” Toms River Patch, 2 July 2017. https://patch.com/new-jersey/princeton/s/g636l/n-j-government-shutdown-continues-as-christie-faces-backlash-video?utm_source=alert-breakingnews&utm_medium=email&utm_term=weather&utm_campaign=alert

 

Healthcare: Treat the Problem, not the Symptom

This is an extraordinarily elegant statement about what’s wrong with the House and Senate bills on “healthcare reform.” According to Dr. Toby Cosgrove, CEO of the Cleveland Clinic,

“If you have more patients coming in that are not [covered], you’re going to have hospitals that are in very deep financial trouble,” Dr. Cosgrove said. “And this is particularly true of rural hospitals and safety net hospitals, which are very dependent on Medicare and Medicaid for their returns.”

Dr. Cosgrove said congressional Republicans’ focus on payment reform instead of healthcare reform is misguided. Instead, they should be trying to identify the “root cause” of the rising costs of healthcare, he told CNBC.

“I think if we came together and deal with the root cause there’d be plenty of money to go around to look after people,” Dr. Cosgrove said. “But if we don’t deal with it now, we’re going to have the same problem going 10 years from now.” (1)

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Sources:

1. Tamara Rosin, “Cleveland Clinic CEO Dr. Toby Cosgrove: BCRA will put hospitals in ‘very deep financial trouble’,” Becker’s Hospital Review, 28 June 2017. http://www.beckershospitalreview.com/hospital-management-administration/cleveland-clinic-ceo-dr-toby-cosgrove-bcra-will-put-hospitals-in-very-deep-financial-trouble.html

Child Mothers

In doing some other research, I ran across this statistic:

• In 2014 and 2015, there were more than 2500 children born to a mother age 14 or under in the US.

In this country? With the information and resources we have?

How much of this is incest?

Why?

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Source: National Vital Statistics Report, Vol. 65, No. 3, 2 June 2016.