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

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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)

 


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

 

The US Economy: Myth and Reality

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Don’t drink the Kool-Aid.

The administration is boasting about a jobs report that is at best mediocre. The facts  are:

  • We added 200,000 new jobs last month. Prior to the 2008 crash, we the standard for a robust economy was 300,000 jobs.
  • Wages are stagnant.
  • The number of workers holding multiple jobs to make ends meet is increasing.
  • The number of people who are underemployed (working part time when they want full time employment, or at a job below their qualifications) is static.
  • Labor force participation remains at or near the low following the 2008 crash.
latest_numbers_LNS11300000_2007_2017_all_period_M07_data

Source: Bureau of Labor Statistics

As I’ve stated previously, the unemployment number is an artificial misrepresentation of reality. That number excludes anyone not activity seeking work. After 26 weeks, when unemployment insurance expires in most state, there’s no reason for anyone to report whether they are looking for work or not. These “long term unemployed” aren’t included in the unemployment rate calculation.   That’s why the labor force participation is the more meaningful number. (By the way, other countries don’t misrepresent unemployment the way the US does.)

The real numbers are buried in data reported by the Labor Department.

US non-institutionalized population:          255,155,000
In labor force:                                                  160,494,000 (b)
Unemployed in labor force:                              6,981,000 (a)
Not in labor force:                                             94,657,000
Want job, not in labor force:                             5,420,000 (c)

The unemployment rate as reported is a/b. That’s currently the widely reported 4.3% figure.

The more accurate rate is (a+c)/(b+c).  That’s 7.4%.  And that number doesn’t address under-employment.

A classic case of underemployment is the insurance industry. The industry primarily uses unsalaried “independent” agents (people who get paid on a commission basis) and the washout rate for first year agents exceeds 98%. Yet, until they washout, the government considers them employed.

Why the high washout rate? Well, as a ballpark, with supplemental insurance (accident, cancer, etc.), an agent makes $100 per policy sold. For a first year agent to make an income that exceeds poverty level requires the sale of 150 policies, not impossible, but not easy to do when there are millions of others trying to do the same thing, and a lot of viable prospects already have policies with which they are satisfied.

Another contrary indication about the economy is per capita gasoline use.  It’s down 18% from before the recession in 2008.  Of course there are several other factors contributing to that decline:

  • Improvement in car fuel economy and introduction of hybrid cars
  • Re-urbanization, and millennials move into city centers, with a reduction in car ownership
  • Replacement of car ownership with Zipcars, Uber and Lyft
  • The growing population of seniors who drive less
  • Replacement of face-to-face contact with social media and Skype

However, a key element underlying these factors is that cars have become unaffordable for many consumers. Between car payments, parking and insurance, the cost is simply too high for too many.

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Recovery? What recovery?

Prudence says to prepare for a slowdown in housing and another round of layoffs. 

Unless you see a mushroom cloud on the horizon on some future morning.

In that case, the economy will be irrelevant.

 


Sources:

  1. Pedro Nicolaci da Costa, “The number of Americans holding multiple jobs is sending a ‘troubling’ message,” Business Insider, 8 August 2017. https://www.aol.com/article/finance/2017/08/08/the-number-of-americans-holding-multiple-jobs-is-sending-a-trou/23070442/?brand=finance&ncid=txtlnkusaolp00002412
  2. https://data.bls.gov/timeseries/LNS11300000
  3. Jill Mislinski, “Gasoline Volume Sales and our Changing Culture,” Adviser Perspectives, 24 July 2017. https://www.advisorperspectives.com/dshort/updates/2017/07/24/gasoline-volume-sales-and-our-changing-culture

Drug Profits in the US: Who Gets What?

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Conflicts-of-interest in the distribution of prescription drugs are driving health pillsinsurance 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.

 


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

Situational American Morality

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A new study from the University of Illinois at Chicago has implications for both politicians and advertisers — and should scare anyone who cares about ethics.

The study involved having consumers

. . . read a political monologue about federal funding for Planned Parenthood that they believed was previously aired over public radio.

Respondents were randomly assigned one of two feedback conditions where upon completion they were informed that the monologue they had just read was either true or false.

Consumers were then asked whether they felt the monologue was justified. The bottom line:

  1. If the consumer agreed with the monologue, they were less critical of it, regardless of whether they were told it was true or false.
  2. If the consumer disagreed with the monologue, they were more critical of it regardless of whether they were told it was true or false.

In other words, in today’s America, it doesn’t matter if someone is telling the truth or lying as long as the consumer agrees with what they are saying. Functionally, that’s a blank check for a politician or advertiser to say anything as long as it includes something the consumer wants to hear.

Unfortunately, this “culture of lying” has consequences. It affects where people want to live, work and spend their money.

As an Airbnb host, we’ve been getting an earful from foreign travelers who don’t want to live here as well as workers who are asking for transfer back to their home countries. We have a doctor who views the level of medical errors in the US as unacceptable and disgusting. We have the Irani who says that, if she becomes ill, she will return to Iran for treatment rather than seek treatment in the US. We have a mother from Europe who is leaving so her daughter won’t become “Americanized”. We have the black teacher who grew up in the US and now works in Saudi Arabia, and says that her quality of life is better there than it ever was in the US.

We have the realtor from Kansas who lives in an American enclave near Mexico City and has seen a 41% increase in sales to Americans moving south this year. Mexico claims that it has 2 million Yanquis living there, most undocumented immigrants. South Korea has close to 1 million Yankee civilians; there are other large pockets in UK, Saudi Arabia, Costa Rica, Australia and other countries. The US Government itself is mum on the number of Americans leaving the country. (All of these numbers exclude military and government personnel stationed outside the US.)

A primary complaint among expats is that they want to escape what the US political culture has become. That brings us back to our topic — the moral acceptability of lying.

For some of us, lying remains unacceptable regardless of the excuse.


Sources:

  1. Allison B. Mueller, Linda J. Skitka. Liars, Damned Liars, and Zealots. Social Psychological and Personality Science, 2017; 194855061772027 DOI: 10.1177/1948550617720272
  2. University of Illinois at Chicago. “We tolerate political lies for shared views, study suggests.” ScienceDaily. ScienceDaily, 3 August 2017. <www.sciencedaily.com/releases/2017/08/170803145640.htm>

Diabetes: Best and Worst States

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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.


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

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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?


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

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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.

chart

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.

chart(1)

chart(2)

(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?


Sources:

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