Archive for the ‘medicare’ Category

Merrill Goozner Bio

09.14.2006 The Amgen Rip-off (6 comments ) READ MORE: 2006, Washington Post, George W. Bush
Medicare spends more money on Amgen’s Epogen than any other drug in its medicine chest — $1.75 billion in 2005. Virtually all of it went to patients on dialysis. (The agency also pays for the same protein for cancer treatments, but those are sold under the brand names Aranesp by Amgen and Procrit by Johnson & Johnson.)

Given that level of spending, you’d think there would be pretty good evidence that this drug, which raises the red blood cell count, is delivering positive results for the unfortunates suffering from what the government and physicians euphamistically call “End Stage Renal Disease” (ESRD). The euphamism refers to the fact that the average life expectancy of a person who enters dialysis after their kidneys fail is about five years.
You’d think that but you’d be wrong. In fact, the evidence suggests just the opposite. Of course, treating the anemia associated with kidney failure was a godsend when Epogen first came on the market in 1987. It ended the need for blood transfusions, and allowed dialysis patients to have red blood cell counts (hematocrits) near normal.
However, the Food and Drug Administration’s initial approval for Epogen called for raising hematocrits to about 15 percent below normal. While most patients don’t notice the difference, Amgen, through a series of studies it funded, attempted to show that higher hematocrits were better for patients. Their measuring sticks? “More energy” and “greater alertness.” Through intense lobbying, they used those studies to browbeat Medicare into reimbursing dialysis clinics to raise hematocrits to slightly below normal. Not surprisingly, in the wake of that 1997 decision, Medicare spending on Epogen soared.
But what were the medical results of that policy? In a paper published in 2004 in the Journal of Clinical Epidemiology, Dennis Cotter of the Medical Technology and Practice Patterns Institute and his colleagues at Johns Hopkins and the Boston VA showed that attempts to reach normal hematocrits, which required LOTS more Epogen, did not correlate with increased longevity for people on dialysis. In fact, they showed that raising ESRD patients’ hematocrits to normal levels actually resulted in shorter lifespans because it increases the incidence of heart attacks, strokes and other cardiovascular events.
Gee. You mean thickening the blood in people who have severe microvascular distress from a lifetime of untreated hypertension and diabetes (which are the primary causes of kidney failure) causes heart attacks? To quote that famous line in Casablanca, I’m shocked.
Now, Cotter and colleagues are back in the latest issue of Health Affairs (subscription required), bringing us up to date on the Bush administration’s policy on Medicare spending for Epogen. In a move that NO ONE in the mainstream press covered (Hey, another half billion dollars in drug spending? Who cares?), CMS this past April gave dialysis clinics the okay to raise patients’ hematocrits to 39, which is normal for women and a shade under normal for men.
If Cotter’s earlier paper is correct, the end result of this policy will be shorter lifespans for many dialysis patients, but greater sales and higher profits for Amgen. To use the dry language of the Health Affairs study, “CMS has tacitly implemented a policy that does not appear to confer additional proven benefit to its beneficiaries.”
What would Cotter do about it? First, improve the evidence for drugs Medicare buys. Payment decisions should no longer be based on surrogate markers like the relationship between higher hematocrits and a subjective measure like “more energy.”
Second, the agency should require randomized clinical trials, systematic reviews and meta-analyses to prove that a drug it pays for results in better outcomes for patients. In addition, since the companies selling the drugs have a stake in the outcome, those trials, reviews and analyses should be conducted by physicians without conflicts of interest.
Finally, if CMS doesn’t have that kind of evidence generated in independent studies, it shouldn’t pay for any drug that has not been prescribed for an FDA-approved use and at an FDA-recommended dosage.
This past week, Bernadine Healey, the former head of the National Institutes of Health, launched a wrong-headed attack against evidence-based medicine in U.S. News and World Report. (For a good blog entry attacking her article, see Gavin Yamey’s latest posting on the PLoS Medicine website.) The Amgen-Epogen-dialysis saga is a perfect example of how ignoring the evidence is costing taxpayers a bundle.
Meanwhile, economic pundits like Robert Samuelson (see today’s Washington Post) rail against increased Medicare spending (even though its costs are rising at a much lower rate than overall health care spending, a fact I wish he had mentioned in today’s column).
But I agreed with his larger point, which is that uncontrolled health care spending (not just Medicare) will bankrupt the rest of the economy if left unchecked. But how should we rein it in? But cutting benefits and raising first-dollar coverage so people will simply stop going to the doctor for minor ailments and preventive care?
That would be a tragedy. What we need now are reporters in the mainstream media willing to go after companies like Amgen that rip off Medicare. Of course, we also need courageous editors willing to ignore the fact that the drug industry’s full page ads are a major prop in their shrinking bottom lines.
But that’s another story.

gleaned from the dialysis_support list (thanks Kim!)

What an eye opening article, and so objective! :)

Yeah, Epogen sure is a ripoff – nobody notices small increases in oxygen carrying capacity of red blood cells – that’s why so many cyclists utilize it to gain increases in their hemadocrits – because people can’t tell the difference.

Where this article fails (aside from its blatant bias) is in assuming that patient longevity is the sole purpose of dialysis. Just because Epogen isn’t prolonging life doesn’t mean it is a ripoff. In fact, I don’t think its use is for extending life, rather for improving quality of life, particularly for those dialysis patients still active in their lives.
For most of us, End Stage Renal Disease does not refer to our last stage of life, but our last stage of renal function. Most of do in fact notice a large increase in energy and alertness (I won’t use quotes the way the article does to suggest that these attributes are fictitious) with the use of EPO.
I think the real issue here, is not that Amgen is ripping off Medicare, but that Medicare is ripping off dialysis providers, and the providers are combating their losses by prescribing more epogen. Why not after all, Medicare is paying for more EPO, when it won’t pay more for dialysis treatments.

Contact Your Local Representative: The Kidney Care Quality Improvement Act

It takes less than two minutes.

Medicare is not just for seniors, it’s used by many people in different age groups and demographics – and for many it is their only access to life saving health care. Take me for example: I’m 29 years old, and un-insurable privately. That makes it really difficult to receive the life giving dialysis treatment I so desperately need.

Medicare pays for 80% of my dialysis treatment – that is – 80% of a number that is nowhere near what dialysis is worth.
Right now I think that number is somewhere around $130.00 per treatment.
The actual cost of treatment to the provider is several hundred dollars more.
That number isn’t made up – it’s based on actual costs to keep the provider running as a viable business.
Medicare though, has not changed its rate of compensation for something like 30 years, which is why the Kidney Care Quality Improvement Act is so important.
This act simply makes it possible for Medicare to pay dialysis providers more. Not more than they’re worth, but enough to actually keep up a decent standard of care.
You see, when the dialysis clinic has a bunch of patients with Medicare as their primary insurance, they lose money. In fact, they lose between $5 and $10 per patient per treatment. The obvious move for the business would be to disallow Medicare patients – but they can’t do that (thankfully). They do need fair compensation though. The result of this loss is the hiring of less staff members (we’re already well below what should be an appropriate staff/patient ratio). Also, the staff we do get are paid less, and as such are less likely to really be proud to be making the difference in lives that they are.
“Big deal” you say.
Well, every time I write about staff not changing gloves, or sticking a patient poorly, or doing some other inappropriate thing – someone’s life is honestly and truly on the line. Not changing gloves can EASILY lead to an infection. I don’t know if you know this, but the odds of leaving the hospital healthy after entering with an infection aren’t that great.
Bad sticking affects our accesses. These are quite literally our life lines, and even one bad stick can lead to clotting, and eventual loss of an access. I have been fortunate, but many who infiltrate end up with constant problems resulting in the loss of that access. We only have so many arms and legs, and after that it’s onto catheters – which have a very high infection rate.
See where I’m going with this?
What staff shrug off as a bad stick, or “just forgetting to change gloves” is really incompetence. It can only be addressed through better education, higher standards, and hiring people who understand the importance of their job.
The best way to do that right now, is to allow Medicare to pay dialysis providers what it should for treatment. This brings much needed care to many, like me, who fearfully go to the dialysis clinic, hoping that this treatment isn’t our unlucky treatment.

Please go and make your voice heard

In the last several months we’ve all heard or read about the confusion of Medicare Part D. The media has made it appear as though it is impossible for a Medicare patient to find drug coverage with the new Part D benefit.

After months of reading about what a train wreck Part D was, I became somewhat cynical about the media’s coverage of Medicare related issues. The real story wasn’t being told: how the pharmacies are being affected.
What the media wasn’t telling everyone, was that their local pharmacists were going through hell trying to make this new Medicare plan work.
Local pharmacists were doling out medications to people who weren’t paying, and due to all of the confusion at the other end, the pharmacists themselves weren’t being reimbursed in a timely manner from the Part D providers. Not only that, but the pharmacist doesn’t always know clearly what the provider is going to pay him/her for the drug that they just handed out.
Keep in mind that we’re talking about small locally owned, independent pharmacies. I’m not sure how many of you own, or have owned businesses, but I’m sure you can all understand how hard it would be to stay in business when you’ve given most of your inventory away without any payment.
One local pharmacist told me shortly after the onset of the Part D coverage, that he had given out over $30,000.00 in medications, without yet receiving even a penny from any of the providers. They make the process of being reimbursed complicated enough, that it takes forever and a day for the pharmacist to get anything back. The bottom line is: a pharmacist can’t stock the shelves with medicine if he doesn’t have any money to buy it from the manufacturer.

With the very real possibility of all the small pharmacies closing down due to Medicare Part D coverage, some politicians are finally making a move to level the playing field.

Earlier this week a bipartisan group of U.S. Senators sent a letter to CMS encouraging some changes in how things are run. The letter urges CMS to better regulate the providers of Medicare Part D prescription drug coverage, demanding that they make clear up front their reimbursement of the medications they cover. The letter also urges them to make possible EFT (Electronic Funds Transfer) to the pharmacists selling the medications, making reimbursement that much faster. The letter also encourages CMS to insist that providers update the wholesale drug lists daily, to make it easier for the pharmacists.

From the letter:

“We strongly encourage the agency to examine PDP activities that may undermine beneficiaries’ access and to consider the suggestions we offer to promote strong and continued participation of local, community pharmacies in the Medicare prescription drug plan,”

I think this might be a step in the right direction. I for one value my local pharmacy, and would like to see it possible for him to stay in business through all of this. As more and more insurance companies dump their prescription coverage for any of their members who qualify for Medicare, there will be more and more patients joining Part D coverage. This means more medicine that the independent pharmacist is selling at a reduced profit margin.
I’m torn between wanting to support the local guy, and my inability to pay for all of my necessary medications. Hopefully we can find some in between state that will work – and this letter may be a starting point for creating that.
Time will tell.

No.
The health care they receive is very very expensive, and you and I are paying for it.

Forgive me to not referring to these people as “undocumented workers” – they clearly are, but they’re also here against the law, making them illegal.

This issue seems so multi-faceted, it’s hard to find a “side” that makes sense isn’t it?

No, it isn’t.

I do however understand the people arguing for immigrant’s rights and such. Lots of great points are made about denying children vaccines and the helpless people affected by such actions. Throw in the fact that the country they’re coming from is doing nothing for them, and it seems so clear that they should be welcome here.

They ARE welcome here!
Nobody is arguing that Mexicans shouldn’t be allowed into the country. We’re saying that they should commit to becoming U.S. Citizens, and come in legally.
Almost all of us come from an immigrant family – my family arrived here only 60 years ago.

I’m PRO-Immigrant.
I’m also of the mindset that some sort of rules need apply to who comes into the country, and how.
People speak of the economic burden we will all incur if we no longer have such cheap labor. I’m sorry – more of an economic burden than we are currently carrying due to increased education and medical costs?

The medical part of this really gets me.
Should I be blessed with children, I will have to vaccinate them. I will also have to pay for it. As a dialysis patient dealing with chronic illness, I’m all to familiar with health care costs and the rate at which they can destroy someone.
Being chronically ill makes me uninsurable. Thankfully Medicare picks up a part of the tab, and with help from some other organizations, the rest of the tab gets picked up — for dialysis costs anyway.
I qualified for Medicare though, because I had already paid into Social Security for a predetermined amount of time. Otherwise I would most likely have Medicaid, and would still be “taken care of”.
As it is, I pay out of pocket for everything not dialysis related. If my wife becomes pregnant, or if I break my leg, we will have to pay for the care we receive.
Before someone yells “but you can afford it!” – no, we can’t.
It’s not really about who can afford it though. If American citizens regardless of their economic status aren’t privy to socialistic health care, why should illegal immigrants living here receive such treatment? Are we that enamored with cheap Big Mac’s and cheap produce that we’re willing to make such obvious, and glaring sacrifices?

Speaking economically, wouldn’t Mexico’s economy greatly improve if all their workers weren’t being encouraged by their government to leave? If their government were more proactive in encouraging people to stay and work, wouldn’t it give opportunity for economic growth?

Come here
Come here if you’re willing to be an American, and help to make America a better place, rather than taking advantage of it.
Otherwise you are insulting every single person who read The New Colossus on the base of the Statue of Liberty as they first arrived in this country.

I’ve been hearing for so long that Medicare Part D was going to be the best thing since TAB soda, but I haven’t seen anything yet to indicate that it would be.
I recently wrote a couple of entries about Medicare Part D and how selecting a plan was very simple (contrary to what the media would like us to think).  And while I had selected a plan which appeared to be great (saving me about 50% annually), I hadn’t yet actually tried to purchase any medications.

Today of course, was that day.

I went into the pharmacy and asked: “Hey, are you guys part of the soandso network?”

“yes”

“Great, I need these scripts filled please.”

“cool bro, that’ll be just a minute.”  (they don’t actually call me ‘bro’ … but it sounds cool).

“………..”

“Hmmm…  it seems that your Phoslo isn’t covered.”

*screeeeeach*  

At this point in my story, I’d like to explain something.  Phoslo (Calcium Acetate) is something I take to keep me healthy longterm.

One of the amazing things your kidneys do is to help keep your calcium and phosphorous levels in balance.  If one of these levels becomes too high, or too low, the other will rise or lower to help balance out.  So without kidneys to pull phosphorous out of my blood, the level of phosphorous rises in my body, and my parathyroid kicks in (secreting the parathyroid hormone of course).  This hormone once released essentially tries to pull calcium out of other places to balance the higher phosphorous.  Yes, this means that bones and teeth for example can become weaker.  Not to mention the higher amount of calcium floating around in the blood can calcify and lead to some nasty “stuff”.  So I take Phoslo with each meal to bind to the phosphorous in my diet, thereby keeping this level in check.

Needless to say Phoslo is an important medication for me – it is also the most expensive one I take.  I have been paying out of pocket for it (roughly $150 a month, which is significant for us right now), and now with Medicare Part D was lead to believe I would have coverage.

I was a little peeved to hear from the pharmacist that the one drug I needed covered was not.  After all, that’s why I selected the plan in the first place!

Walking to the dialysis clinic without my Phoslo in hand, I tried to figure out how to proceed.  Naturally I called these greedy (insert word here), and tried to find out why their formulary listed Phoslo as a “preferred” drug, but denied my claim when I tried to purchase some.  I did this in a polite way of course.  After 20+ minutes on hold, I was told that they did cover it, but that my pharmacist had requested too many.  I then explained why it was necessary for me to have 400 tablets a month, considering that I take a hand full of them every time I eat.

Finally the coverage was approved by their pharmacy guy, and hopefully when I go back to my pharmacy guy, it will go through.

The whole thing freaked me out a little bit though.  What’s to prevent one of these companies from listing a drug that 300,000+ American dialysis patients need in their formulary, only to drop its coverage weeks later after collecting our premiums?

Let’s hope they come through – a break would be nice.  Very nice.