Archive: June, 2012
Robert I. Field
by Robert I. Field, Ph.D., J.D., M.P.H.
OK. I was wrong. I predicted the Supreme Court would strike down the mandate in the health reform law.
But at least I was in good company. Few people expected the mandate to get a clean pass.
However, on another key aspect of the ruling, many observers (this one included) were correct. It was extremely narrow. The decision rests on settled constitutional principles of tax law, not on a novel expansion of federal power. (The full opinion is available here. A summary of key aspects is available here.)
Daniel R. Hoffman, Ph.D.
A few days ago Andrew Witty, GlaxoSmithKline's CEO, gave vent to the industry's consternation over the fact that European countries, in their efforts to control drug costs, have resorted to more "reference pricing." Plainly stated, that means the Europeans are basing the allowable prices within their own countries on what low-priced neighbors such as Greece and Rumania will allow. Along with that, arbitrage drug trading within the continent has also increased, meaning traders will buy drugs for super-low prices in Greece and sell them for a markup in France at prices that are still below what the French would otherwise pay.
Witty is currently serving as president of a trade lobby, the European Federation of Pharmaceutical Industries and Associations. His remarks are best viewed within the context of expressing the industry's resentment at being considered a mature sector that governments will no longer coddle. To the contrary, European nations during this recession are controlling drug prices more aggressively because they expect pharma to shoulder a burden commensurate to the margins it has enjoyed over the past 30 years.
The remarks by Witty provide a companion piece to Joe DiStefano's article that summarized the results of a survey taken by fund manager John Coyne and his team at Brinker Capital Inc. Coyne polled his high net worth clients and found that for a majority of them, their top "concern is that a Democratic administration is going to try to bail out the deficit on the backs" of the wealthy. Worries about a stagnant economy, home foreclosures, lagging job gains and a European financial crisis creating a U.S. recession all stand well behind the one-percenters' tax fears. The prospect that they may have to pay tax rates comparable to what their rich counterparts did from the 1950s through the 1990s has led them to create a fictional bogeyman out of a moderate-conservative president.
The survey results, together with Witty's comments and the rantings of Tea Partiers and their clones all reflect the resentment of established, corporate and individual (largely white) segments that feel themselves threatened, either economically or culturally. They abhor that the U.S. is rapidly becoming a country of predominantly ethnic minorities and they refuse to acknowledge that Obama is conservative in the manner of every president since FDR — he wants to use the government to preserve existing institutions. The mythmakers focus instead on his multi-racial, multi-cultural cosmopolitanism as a rebuke to their sense of specialness and entitlement.
In a major win for the White House, the Supreme Court in a 5-4 decision upheld President Obama's overhaul of the nation's health care system.
The court said that a central feature of the plan, that individual Americans purchase insurance or be subject to a penalty levied by the IRS, was constitutional. It also upheld a provision greatly expanding Medicaid, the health care program for the poor jointly financed by the state and federal governments.
What does all this mean for you? Our expert, Robert I. Field, Ph.D., J.D., M.P.H.,answered reader's questions in a live chat.
Field is an expert on health law, health policy and public health. He holds a joint appointment as professor of law at the Earle Mack School of Law and professor of health management and policy at the School of Public Health at Drexel University. He is also a senior fellow of the Leonard Davis Institute of Health Economics at the University of Pennsylvania and a lecturer in health care management at the Wharton School.
by Michael R. Cohen, R.Ph.
Oral liquid antibiotics tend to have short stability periods. So drug manufacturers often provide their products in powdered form and give pharmacists instructions that specify how the powder should be made into a liquid that can be swallowed. Pharmacists normally mix or “reconstitute” the antibiotic right before it’s dispensed and they place a date on the pharmacy label beyond which the antibiotic begins to lose its potency and should no longer be used.
Unfortunately, the pharmacy reconstitution step sometimes gets missed. Just last week a mother called to let us know about an incident where her pharmacist dispensed her 2 year old daughter’s amoxicillin antibiotic prescription in powder form, which she didn’t notice until she arrived home. She realized her daughter couldn’t take the medicine this way so she took the bottle back to the pharmacy. The pharmacist apologized for overlooking the obvious. He mixed it properly and everything turned out fine thereafter.
But patients may not always realize that they shouldn’t swallow the powder itself or give it to their child. If the prescription label says “Take one teaspoonful three times a day” they might take a teaspoonful of the powder, which is way too much since it’s a concentrated powder. In some cases it could cause harm or at least result in having diarrhea.
Robert I. Field, Ph.D., M.P.H., J.D.
by Robert I. Field, Ph.D., M.P.H., J.D.
The Supreme Court is expected to rule on President Obama's health care package Thursday morning.
Predicting the outcome is the hottest game in the health policy world. As anticipation grows, the rising tension is palpable.
What’s the inside line?
Mark Abdelmalek, M.D., is chief of the division of laser and dermatologic surgery at Drexel Dermatology, and assistant professor in the department of dermatology at Drexel University College of Medicine.
In many ways, acne on your cheeks is the same as acne on your, uh-hum ... "cheeks." It's basically a plugged up hair follicle that gets inflamed.
There are a few things you can do. You can start washing with an acne wash in the shower. Benzoyl peroxide works well and there are now prescription strengths of benzoyl peroxide available over-the-counter. Benzoyl peroxide washes can be irritating so don't overdo it. Start off with lower strengths around 5 percent, but if you're not too sensitive and are tolerating the 5 percent strength well, try 10 percent. And, an important warning for your wardrobe and your wallet — benzoyl peroxide can bleach your towels and clothes so be sure to rinse well. It might be a good idea to wear white undergarments and use white towels.
For people who don't have sensitive skin, antibacterial soaps also may help. Antibacterial soaps can be very harsh on the skin and may be too drying, especially in the winter, so again, don't overdo it.
Daniel R. Hoffman, Ph.D.
by Daniel R. Hoffman, Ph.D.
A study by the federal government's Centers for Medicare and Medicaid Services reported last week that by 2021, health care spending will consume 20 percent of this country's GDP. Even people with good health insurance that includes a prescription drug benefit should not remain blasé about these escalating costs because more policies are changing to shared risk coverage. Under that sort of system, out-of-pocket costs are not limited to standard deductibles and co-payments. They also include a percentage of a drug's total cost.
If rising health care costs will eventually squeeze the public here and in other developed countries to demand some form of price controls, the pharmaceutical industry believes it already has the matter covered. Pharma is doing two things to retain profitability amidst lackluster new products and a stiffening price resistance among payers. The first trend involves adopting an orphan drug strategy across many therapeutic areas. That would mean per patient costs for each medication will range from $50,000 to $250,000 per year. In other words, if someone can afford to pay $10,000 to $50,000 per year for his/her medication, life can continue. Otherwise, dignum morte. One segment of 60 Minutes is about all it should take to cook that goose.
Secondly, the rapidly industrializing economies in China, India, Brazil and several other countries, each with a growing middle class, have inspired pharma to focus more of their drug development, production and marketing efforts there.
Michael R. Cohen, R.Ph.
Michael R. Cohen, R.Ph.
Pharmacists and nurses that prepare and administer cancer chemotherapy drugs are at constant risk of exposure to toxic substances that can harm them personally. When these drugs are spilled or sprayed by accident they can be absorbed through the skin or the vapors can be inhaled. Without a doubt, the biggest fear is that prolonged exposure can lead to gene mutations, reproductive problems and even cancer. A 2010 story about a Pacific Northwest caregiver who developed cancer is particularly alarming.
The Occupational Safety and Health Administration (OSHA) classifies cancer chemotherapy drugs as hazardous, and they’ve published recommendations for protection from occupational exposure. In addition, in 2004, out of concern about this “second hand” chemotherapy exposure, the U.S. National Institute for Occupational Safety and Health (NIOSH) urged strict precautions and also issued guidelines for handling chemotherapy, including use of protective gear like gowns and gloves. The American Society of Health-System Pharmacists (ASHP), and the Oncology Nursing Society (ONS) also have guidelines that call for donning protective gowns.
Covidien is one of the companies that provides gowns for cancer workers. One of their products is called ChemoPlus. Looking at the product name, health professionals may believe that ChemoPlus Protective Gowns offer the kind of protection that pharmacists or nurses need against personal exposure to chemotherapy drugs. Unfortunately, the name is misleading. ChemoPlus does not afford the kind of worker protection called for in the professional guidelines.
Babak Vakili, M.D.
Al D’Angelantonio III, D.P.M., Foot & Ankle Surgeon in the Department of Surgery at the Hospital of the University of Pennsylvania
Don't worry. Developing thickened, discolored toenails is a common concern for men and women of all ages. Although there are many reasons that this can happen, it is most often caused by a fungus. Now this sounds a lot worse than it is, but what may be causing your toenails to become thickened and discolored is a “dermatophyte.” It’s a type of microscopic fungus that is invisible to the human eye and loves to hide in dark places like shoes and nesting themselves - you guessed it - right underneath your toenails.
Again, don’t panic. The good news is that these dermatophytes only stay locally to the toenails and do not spread into your blood stream. Other types of dermatophytes can invade the hair and skin. They also won’t cause you to become systemically sick. The bad news is that once the fungus gets underneath your toenails, it is difficult to permanently remove.
If your doctor diagnoses you as having a toenail fungus, you may hear the term “onychomycosis.” Your doctor may test for onychomycosis by sending a clipping of your toenail to a lab where they can look at it under a microscope to detect if the dermatophytes are present. Although being diagnosed with onychomycosis might sound awful, with patience and consistent treatment, your toenails may return back to their normal appearance. However, the longer you wait to treat the toenail fungus, the more likely it is that your toenails may remain permanently discolored.
Daniel R. Hoffman, Ph.D.
by Daniel R. Hoffman, Ph.D.
Here are some impressions from the recent American Diabetes Association annual research meeting at the Pennsylvania Convention Center. (See full coverage of the conference.)
- This meeting seemed somewhat smaller than those of past years. That was evident in terms of both the number of booths on the exhibit floor and the opulence of those that were there. That's probably a good thing because it likely means the pharmas at least wanted to tone down the appearance of staging a huge marketing and payoff bazaar.
- A larger proportion of attendees were physicians from outside the U.S. Some exhibitors even cited ADA registration figures that showed 60 percent of attendees at this ADA meeting came from foreign countries. That may be good if it means more physicians are flying in for the scientific sessions. Correspondingly, it would also mean fewer physicians, especially in the U.S., come looking for freebies such as continuing medical education courses that are inevitably biased to favor the products from sponsoring manufacturers. Then again, a higher proportion of foreign physicians may simply mean that manufacturers are targeting more of their marketing efforts to the emerging markets because practitioners there can be swayed more easily and for less money.
- The celebrity perks that pharmas bestow on KOL (key opinion leader) presenters appear less overt. It's probable that the companies still treat big-name investigators with the same sort of wine 'em and dine 'em benefits that defense and homeland security contractors give to military brass, but conditions these days keep it under tighter wraps. Despite the general appearance of less opulence, however, some people overheard a prima donna diabetologist emerging from a parked limo on Arch Street as he berated his sponsor's minder for failing to stock the back seat cooler with the right Pinot Noir.
- A growing number of studies show healthy lifestyle is a more important determinant of longevity and well being than what was previously believed. Another study that came to this conclusion appeared just a few weeks ago. Diabetes is one condition where this finding appears especially relevant, yet pharma's commitment to wellness and prevention still consists mainly of promotions intended to hype their products. As noted in a Sunday Inquirer column, pharma creates a counterproductive attitude among the general public by taking this approach. Instead of encouraging healthy living patterns, the over-medicalization of everyday life fosters the idea that more pills will solve everything. This pills über alles mindset promotes the notion that unhealthy ways of living are themselves medical conditions that require still more pills.
Finally, pharma is by no means the sole or even the major delinquent in the matter of diabetes as a public health problem. News of that appeared outside the ADA in an excellent article published by the UK's Guardian. It shows how the food industry deserves more of the blame for increasing rates of obesity and diabetes. The problem began as far back as the 1970s with the use of corn sugar as a sweetener. At the same time, the U.S. under the Nixon administration adopted the approach of an uncontrolled market as the answer to everything. The administration's Agriculture Department encouraged a more corporatized approach to farming for global customers that resulted in extremely large serving portions.
So in part, the ADA was a distraction from reality where more answers to the public health problem of diabetes depend on an altered political economy instead of results from the lab or the clinic.