No Bias Anywhere Here: The Future Of Bias
Some drugs are covered by insurance, some are not; insurance companies have medication formularies. e.g. Zoloft may be covered, Lexapro might not be. If a doctor wants to use Lexapro, he has to fill out a prior authorization form detailing his reasons for choosing the non-formulary drug. The request can be allowed or denied. The point of it is simply to-- nudge-- the doctor towards the formulary drug.
BACKGROUND: Prior authorization is a popular, but understudied, strategy for reducing medication costs. We evaluated the impact of a controversial prior authorization policy in Michigan Medicaid on antidepressant use and health outcomes...CONCLUSIONS: Prior authorization was associated with increased use of preferred agents with no evidence of disruptions in therapy or adverse health events among new users.
What do the authors want to be true?
I.
First, let me explain why the conclusions of this study, (prior authorization leads to a "substantial public health benefit and cost savings" (as the editor summarized in his editorial entitled, "The Change We Need In Healthcare" (yeah, that's what he called it; soon we'll see "Dopamine Blockers in Schizophrenia: Mission Accomplished"))) are completely misleading.
Despite what you and logic might think, insurance companies and Medicaid do not pick their formulary based on what is most efficacious, or even what is cheapest. They put things on based on the deal they strike with the drug companies. By "deal" I mean "payoff." By "payoff," I mean "kickback," in a mechanism so needlessly complicated it can only be on purpose. Many "non-preferred agents" are cheaper/better/safer than the "preferred agent."
If we move to a single payer model (BTW: will never happen, ever, I'll explain why) that payer may be able to negotiate lower prices overall, but it will be because of the "deals" and not because of judicious evaluation of safety or efficacy. If the FDA can't competently evaluate safety and efficacy, do you think Medicare can, and still account for the third variable of cost? And what would we need doctors for?
And think about the way the clincial decision is made. These deals occur outside and before the doctor-patient interaction. The doctor has no choice but to use the products available to him. He has the option of going off-formulary, but it is so difficult that it is impractical. In other words, Pharma and the insurance company have colluded to control the market. You didn't like it when Microsoft did it. Isn't this the definition of racketeering?
II.
What do the authors want to be true?
I know what a "Department of Ambulatory Care and Prevention" is. But do you know what a "Harvard Pilgrim Health Care" is?
Oh, they're the same thing.
III.
Imagine if Harvard's department of surgery was sponsored by Intuitive Surgical; or their psychiatry department was sponsored by Pfizer. Imagine those pairs then went on to make policy decisions, like teaching residents that the DaVinci system is first choice for surgeries; or teaching med students that Zoloft is first line for depression. Those would seem like conflict of interests that would never happen in today's anti-bias climate. But there you go.
You might not think this is as bad as Pfizer running the Harvard Psychiatry, but it's actually much worse, because there are competing alternatives to Pfizer but there are no alternatives to insurance-- especially if we get a single payer.
I'd like to point out that Harvard has banned drug pens from the school because that influences prescribing.
What are the chances that an academic at Harvard on the brink of becoming Associate Professor is ever going to "discover" that preferred drug lists aren't a good idea?
If you want to see what the next ten years in medicine look like, stop looking at Astra Zeneca. The next unholy alliance is between academic medicine and insurers/providers. The placebo controlled trials on the treatment of bipolar will no longer be controlled by Abott (Depakote off patent 2008), but by United Healthcare.
Academics won't be scrambling to get Pharma grants; they'll be looking for Aetna grants. And ten years from now, when we finally wake up, we'll be asking how we let insurance companies and government ever get so close to medical education, how we let them "corrupt" our residents.
While we were distracted by Carlat for repenting his Big Pharma ways, no one noticed the answer:
The answer is: some spots opened up, and they were available.
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May 11, 2009 3:41 PM | Posted by : | Reply
I wonder how moot feels about this...
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May 11, 2009 11:08 PM | Posted by : | Reply
Thank you for these tremendously educational posts.
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May 12, 2009 9:06 AM | Posted by : | Reply
Why will the health funders, the insurance companies, care about (seemingly) empirical evidence?
Thus far, they have been able to simply declare what they will and will not allow (formulary, util review, in-network, etc.), or will allow if you jump through the hoops (prior auth, etc.). No need for a peer-reviewed article to wave in front of a doc over lunch.
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May 12, 2009 11:03 AM | Posted by : | Reply
You obviously are not from MA. Charlie Baker is probably the next governor of the state.
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May 12, 2009 11:22 AM | Posted by : | Reply
What do we do about it?
Seems like the problem of "The people with money have the free time and resources to devise new schemes of making money. While everyone else is lucky if we can make enough money to live month to month, the unlucky ones are living day to day"
What solution options do we have:
We can not invest in health insurance... THAT'LL Show EM!!
We can avoid doctors who have been a part of this horrible system.... That's possible.... right?
We can vote for the least worst.... THAT's been working well..
We can.... .... ...
In my opinion... there will always be crooks, due to the information age, their lies and webs reach further/faster, but they have always been there...
As it stands, I think we're still better off in America, no matter how many messed up systems we have. People risk life and limb just to live in poverty here, because its better than where they came from.
I think the larger problem of the system is the expectations we place on it.
Health care can't make us live forever...
Unbiased is impossible...
Everyone can't have Everything they want...
Living for free.... (someone somewhere has to pay for it)
In the end, no matter what system you look at in our society, it was either made by humans or comprised of humans, which means it is prone to errors, problems, bias, etc...
So what are you gonna do?
Bury your head in the sand? ... you can if you want..
Burn it all down and start over? ... I'd rather not...
Do the best we can with what we got? I'd say that's about all we can do.
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May 12, 2009 12:55 PM | Posted, in reply to , by : | Reply
Dude, have you been in your Mom's (unwired) basement since January? We're in the era of Hope and Change. We don't have to think about all these weighty questions any more.
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May 12, 2009 9:50 PM | Posted by : | Reply
Its the change you aren't aware of that gets you.
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May 12, 2009 11:32 PM | Posted by : | Reply
Please please please don't ever stop writing. I've been reading your blog for quite some time now and although there have been times I've disagreed with you, the level of discourse and analysis is incredibly thought provoking.
More medical students need to be asking questions and demanding answers.
The Harvard bans pharm pens nearly made me fall out of my chair.
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May 13, 2009 12:16 AM | Posted by : | Reply
I remember seeing a 20/20 special on that pen thing. It's as if the mere presence of some offending logo sends shock waves throughout the poor deluded med student's brain.
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May 14, 2009 2:30 PM | Posted by : | Reply
Seems to be this way in most industries these days.
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June 5, 2009 2:06 PM | Posted by : | Reply
Thank you so much for this.
If you have access to MedCo's prescription drug pricing and coverage information, you can see that this prescription management company has some incredible inconsistencies - for example, Provigil (at a cost of over $1000 a month) is entirely covered with just a $10 copay. Desoxyn and Focalin XR (which, at equivalent doses, cost around $300) are not covered. And if you ended up in the hospital after having an adverse event on generic Adderall XR - which costs nearly as much as the brand name version right now and as much as Shire's new ADHD drug Vyvanse - then too bad for you; brand name drugs when a generic is available will not be covered. They won't even consider covering brand name Dexedrine Spansules, regardless of the low price of $200 for sixty 15 mg capsules, which is far less money than an equivalent dose of Adderall XR, Vyvanse, Concerta, or Provigil costs.
If it were really about money and NOT about deals made between insurance companies, pharmacy benefit management companies, and pharmaceutical companies (including and perhaps especially generic pharmaceutical companies), we might be able to enjoy the benefits that "socialized" European medical systems enjoy - where choices about health are made by doctors and patients and NOT by health insurance companies. You're absolutely right. Single payer is the only system that will work.
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February 4, 2013 10:54 AM | Posted by : | Reply
Another tour de force.
TLP is my spirit guide.
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February 17, 2013 6:57 PM | Posted by : | Reply
Know this is several years late but one word, NICE.
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October 19, 2013 7:36 PM | Posted by : | Reply
My crises of confidence in the medical industry (to include big pharma and medical insurance) came a few years ago as a lay person. Hashimoto thyroiditis. My mother had it (runs in her family) and I came up thyroid impaired at 22. Well luckily there is a pill for that. It solves all your problems. And if it doesn't the endo will cheerfully refer you to a psychiatrist who can prescribe some other pills. Adequately treated thyroid can all be determined by a "range" based on a blood draw.
Now why even bother using a middleman such as an endo is beyond me. Why don't I just go to lab crop on my own - have them draw the blood and have some computer adjust the dose up or down (or not) based on if TSH high or low (or in range)? And wouldn't make more sense to figure why my antibodies are attacking my thyroid and prevent impairment in the first place (too late for me but infuriating because at 9 my SON has elevated anti thyroid antibodies attacking his thyroid though no impairment yet - and I was lucky that the pedi humored me and allowed such testing on a kid who towers over his peers and shows no symptoms of an impaired thyroid).
Well there simply isn't adequate research (at least research funded well enough as the for profit pharma companies can provide) focused prevention. There is a limited study maybe here on there (usually done in a country that isn't the U.S.) on how diet may cause the immune system to turn on itself but nothing definitive and nothing that a U.S. Doc will acknowledge in any way.
Why - because doctors get their knowledge from textbooks and seminars designed to fulfill continuing professional education requirements. The research writes the textbooks. The seminars expound on the newer research that a doc 10 years out from medical school won't know about (I won't get into the more insidious partnering of speakers and universities with the companies they are covertly shilling for).
But what about the research? Where does the research come from. I can't find it now but I have read figures that currently put medical research in the US as being 70 to 80 percent funded by the for profit medical industry.
Well a for profit company isn't going to pour millions of dollars or more into R&Ding something that isn't going to give them an ROI. That isn't how business or capitalism works. So what research gets funded? What research proposals are chosen for grants (in a system in which grants are funded by corporate money mixed with government and nonprofit money)? Will it be the research which prevents people from getting sick in the first place?
I don't even want to get into the agriculture industry and how it has partnered with the very government agencies that are supposed to regulate it to so that our food supply is chock full of everything that will ensure that we need the medical industry's pills.
From a strategic point of view the system is brilliant in its insidiousness. From a "me" point of view it is horrifying.
As a test I went to my Harvard graduated endo (when I was campaigning to throw some T3 into my T4 only regimen) and told him that despite my thyroid being in range I had a hard time with motivation. Going to work wiped me out and drained me such that I had nothing left for anything really and weekends were spent not enjoying my children or anything really except recovering from the last work week & mentally preparing for the next work week. Nothing for my kids or their stay at home dad. I stressed that I wasn't upset about this (ie depressed). Just troubled that I really hadn't been able to force myself to be more present in my life in years).
And as if reading from a script that the thyroid forums prepared me for he said the only thing the medical research directed him to say - see a psychiatrist. Only reason I stayed with him is because he reluctantly added the T3 I requested. I never did see a psychiatrist for what I deemed was essentially a non-acute existential crisis.
So yeah there isn't really anything to be done. The system has taught that to me very well. I can wax poetically about how the corporate system is designed to spread responsibility in such a way that no one person is actually really accountable or how the system of 401ks, and the Everyman in the stock market is a brilliant system designed to redistribute wealth from the middle class to the rich. I KNOW all that but can't do anything but be a part of the system. Right down to being a federal employee with a TSP.
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October 19, 2013 7:41 PM | Posted, in reply to , by : | Reply
Sorry for the grammar errors, the omission of entire words, and the strange jumbling of some of the thoughts above. I suck at proof reading on a tablet and this format doesn't have an edit button that usually saves me after such an occurrence.
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