Tagged Health Industry

Bills, Bills, Bills: Readers And Tweeters Offer Solace, Solutions And Scoldings

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.


2018 was a busy year for KHN, harvesting more than 1,200 medical bills submitted by readers for consideration in our “Bill of the Month” franchise, an investigative partnership with NPR. These monthly dives into patients’ cumbersome bills continue to spawn stories — as well as proposed changes to health care policy by legislators.

Sen. Bernie Sanders (I-Vt.) glommed on to the despair of an Arizona couple consumed by health care debt (“Insured But Still In Debt: 5 Jobs Pulling In $100K A Year No Match For Medical Bills,” Dec. 28).

In response to the August “Bill of the Month” feature about a schoolteacher’s $109,000 heart attack, Rep. Lloyd Doggett (D-Texas) tweeted: “When I heard Drew’s story — an Austin teacher saddled with a $100k surprise bill after surgery — I reached out to him to share my concern. We discussed my End Surprise Billing Act legislation, which would end this predatory practice.”

Sanders also shared that story on Facebook, saying: “Our health care system makes absolutely no sense. If you don’t have health insurance, you probably can’t afford to get the care you need. And if you DO have health insurance, in many cases you STILL won’t be able to afford the care you need, on top of paying a monthly premium.”

Outrageous medical bills proved something readers could relate to, as they reviewed our end-of-the-year roundup, Year One Of KHN’s ‘Bill Of The Month’: A Kaleidoscope Of Financial Challenges” (Dec. 21).

— Dr. David Johnson, Dallas


Plaudits For ‘Bill Of The Month’ Series

Thank you for publishing these stories. You are doing a public service. I work in health services research and know that the prices charged by manufacturers, hospitals and other providers are arbitrary. The more citizens are informed about this, the more power we have to change how much health care costs in this country.

— Beth Egan, Minneapolis


— Dr. Edward Hoffer, Boston


‘Bill Of The Month’: Recourse For Wounded Skier

It seems that the surgeon and the device manufacturer should have paid for Sarah Witter’s second surgery (“After Her Skiing Accident, An Uphill Battle Over Snowballing Bills,” Dec. 18). If she truly followed protocol for her rehab, they should have owned up to their mistake or to a poor manufacturing technique. Almost 10 years ago, I had an upper gastrointestinal series performed to monitor my non-Hodgkin’s lymphoma. As a result of the biopsies, I experienced significant bleeding (the doctor said that he had done this procedure several times when the patient was still on blood thinners, which I was). After I was admitted to the emergency room and received four units of blood, they repeated the procedure — and charged me for all of it. Fortunately, after threatening a lawsuit against the hospital and the doctor, they finally paid for the emergency room and operating charges.

There still may be some relief for Ms. Witter: There are companies who audit hospital bills and get paid if they find savings. When the insurance company refused to pay the hospital, they should have referred her to a company that audits hospital bills.

— Dan Kass, chief shopper of HealthCare Shopping Network, Mission, Kan.


On Twitter, readers minced no words:

— Bernie Good, Pittsburgh


— Dr. Judy Melinek, San Francisco


A Dose Of Myth-Busting

Julie Appleby’s story “Short-Term Health Plans Hold Savings for Consumers, Profits For Brokers and Insurers” (Dec. 21) perpetuates a common misunderstanding that incentives for insurance agents favor selling short-term over Affordable Care Act plans.

By comparing a monthly commission rate of 20 percent for short-term plans and a flat dollar amount for ACA policies, the article mistakenly suggests that commission earnings on short-term plans are consistently higher than those that comply with the ACA. But the premise misses the critical fact that the lifetime value of a plan — not the monthly commission rate — determines insurance agent commissions. Short-term plans are both less expensive and held by the customer for a shorter period of time than ACA plans. At eHealth, an ACA plan generates twice the revenue as each short-term policy.

Most insurance agents advocate for consumers to choose an ACA plan first, if they can afford it, because the coverage is far more comprehensive. Unfortunately, many Americans have been priced out of the ACA market and short-term policies may represent the best viable health insurance coverage at a price they can afford. Others miss the open-enrollment period and, without other options, face a year with no insurance coverage at all. The responsibility of a good insurance agent is to help all Americans gain access to the insurance policy most suitable for their individual medical and financial needs. To do anything less is not in the best interest of consumers or to the long-term success of insurance agents.

Scott Flanders, CEO of eHealth, Santa Clara, Calif.


Sad Twist On Knee Replacements

It’s true that doctors do not always tell you the reality of knee replacements upfront (“Up To A Third Of Knee Replacements Pack Pain And Regret,” Dec. 25). I had to have my right knee replaced twice. I had a metal allergy to the first implant, which I found out the hard way.

Patients should be tested for metal allergies before surgery. I am so sorry I ever had my knee replaced — it hurts worse now than it did before the surgery. I would not have my other knee replaced unless I could not walk. I was told my knee would be great until after my second surgery, when my surgeon warned me my knee would possibly always cause me pain. That would have been nice to know before my first surgery.

— Lesa Lawrence, Dallas


— Greg Mays, Nashville, Tenn.


Without knocking total knee arthroplasty, or TKA, a New Yorker wonders whether we’re moving in the right direction.

— Wendy Diller, New York City


Doing The Math On Biologics

The article “Why The U.S. Remains The World’s Most Expensive Market For ‘Biologic’ Drugs” (Dec. 20) mentioned that Cosentyx costs about $15,000 in Europe versus almost $65,000 in the United States. If it is true that someone can purchase a three-month supply for personal use in Europe — and if a three-month supply, properly handled, has a shelf life greater than three months — it seems possible for Susie to go to Italy or somewhere in Europe every three months for an estimated cost of $6,000 a year or less (with tickets purchased in advance). Adding to her travel costs the $15,000 annual cost of the drug, which conveniently can be self-injected, she could still make out far better than paying $65,000 a year in the States. Just a thought.

— Abette Jones-Bey, Blue Bell, Pa.


A tweeter offered one explanation for the pricing disparity:

— Elizabeth Henry, Olathe, Kan.


Sign-Up Season’s Unsung Heroes

Your article on navigators (“Short On Federal Funding, Obamacare Enrollment Navigators Switch Tactics,” Nov. 30) neglected to mention the group of professionals best suited to help consumers select appropriate health coverage: licensed insurance agents and brokers. Agents and brokers typically have more training and experience than navigators. They’re licensed by the states in which they work. The majority have been in business for more than 10 years.

Agents and brokers also work with their clients year-round, not just during the six-week open-enrollment period. A survey conducted by the Kaiser Family Foundation found that more than 70 percent of agents spend “most” or “a lot of” their time explaining coverage to their clients.  It’s no wonder that nearly 84 percent of adults who worked with agents and brokers when shopping for exchange coverage found them helpful — more than any other group offering assistance.

— Janet Trautwein, CEO of the National Association of Health Underwriters (NAHU), Washington, D.C.


— B. Ronnell Nolan, president and CEO of Health Agents for America, Baton Rouge, La.


Entrepreneurs Caught In The Middle

I fall into the situation described in Steven Findlay’s article “Health Insurance Costs Crushing Many People Who Don’t Get Federal Subsidies” (Dec. 14).

If you look at the typical costs for a family earning more than $100,400 a year who don’t qualify for subsidies, the cost is huge. Our current premiums for an ACA-compliant policy are about $1,400 a month with a combined $13,000 deductible for my wife and me (we are self-employed). If you have a “bad year” — say, a car accident where you are both hospitalized — your expenses jump to an estimated $29,800, or nearly 30 percent of your income. This seems to be the strategy of the health insurance companies, whereby they want health care pricing to be a fixed amount of total income. The way they get there is through lack of transparency.

After Supreme Court Chief Justice John Roberts cast the deciding vote around the constitutionality of the ACA “tax” for being uninsured, I left a great corporate job and have since started multiple companies and created jobs simply because getting health insurance through the ACA seemed certain. I am now in the position where I am wondering if I may have to stop my entrepreneurial activities and find a corporate gig again with insurance. I suspect I am not alone in this.

The continued ambiguity around this will have a stifling effect on people like us who are taking the risk to start businesses and create jobs.

— Mick Garrett, Fort Collins, Colo.


— Clayton Mowrer, Kansas City, Mo.


Band-Aid Fixes To ACA Are Like Salt To The Wound

“Ask Emily” columnist Emily Bazar offers a worthy solution that may work for a number of folks and should be explored by those whose household income is slightly above 400 percent the federal poverty level (FPL) (“Without Obamacare Penalty, Think It’ll Be Nice To Drop Your Plan? Better Think Twice,” Dec. 5). But there is a break-even point that may make this solution undoable. Since FPL is a national measure, with just two states receiving an exception (Alaska and Hawaii) to the income ceiling, for anyone who resides in a state with a high cost of living, such adjustments to take-home pay can adversely impact their ability to afford other necessities of life.

Cost of living can vary widely by state or ZIP code, yet the income ceiling for ACA subsidies is set at the national level. Insurance premiums may also vary among counties and even ZIP codes within a state. Some call this market-based pricing or pricing based on an area’s ability to pay (higher average incomes equate to higher premium prices). Still others call it price-gouging. Yet again, the income ceiling is set at the national level.

I welcome any and all ideas that would allow more folks to obtain health insurance (which, by the way, does not guarantee health care coverage). Changes need to be made to the law to level the playing field for consumers. Until all consumers have access to coverage at the same price, with the same level of subsidy be it government or employer, then we truly are putting band-aids on a heart attack. Until your age, marital status, place where you live and size of your employer no longer hinder your ability to afford health insurance coverage, there will continue to be those left out and at risk.

Unfortunately, our elected representatives at both the state and national level have little stomach to face and fix the glitches and inequities in the ACA. Their only remedy, which comes in the form of a tax on the uninsured, has taken the ACA from a solution meant to bring health insurance to all Americans to a policy that relies on those who can’t afford health insurance and are excluded from the benefits of the ACA to fund it. Now that’s ironic.

— Susan Frangione, Rockville, Md.


— Rob Levine, Minneapolis


What’s Really Hurting ACA Enrollment

I can tell you the real reason many Americans gave up on enrolling in an Obamacare plan this year (“Need Health Insurance? The Deadline Is Dec. 15,” Dec. 10).

I had a fairly good health insurance plan under the Affordable Care Act in 2014-15. In 2015, my income changed, and I was eligible for Medicaid under Illinois’ expansion of that federal-state program. However, in July 2018, Medicaid determined that I no longer qualified. I went online to the ACA marketplace to try to find an ACA plan I could afford. To my surprise, the plans available in 2014 were no longer available. The two dozen plans available in my area are not ideal. Some provide low coverage. Some are from carriers that almost all of my doctor groups do not accept. Even some “gold”-level plans have extremely high copays. Though my premium in 2018 did not increase much, it was offset by high hospital copays and burdensome deductible and coinsurance obligations. Prescription copays were percentage-based, not a dollar amount, which made it more expensive to pay for prescriptions.

This is all hurting many Americans in my income bracket. The drop in enrollment in ACA plans is because no one can afford most of these low-level coverage plans in the ACA marketplace. And almost all the ACA plans have limited access to providers, especially specialists, making getting medical treatment nearby difficult. The ACA has been changed and tweaked so that many Americans no longer can afford to buy any of the plans without going into debt if a serious illness arises.

— Lena Conway, Naperville, Ill.

Emergency Medical Responders Confront Racial Bias

A recent study out of Oregon suggests emergency medical responders — EMTs and paramedics — may be treating minority patients differently from the way they treat white patients.

Specifically, the scientists found that black patients in their study were 40 percent less likely to get pain medication than their white peers.

Jamie Kennel, head of emergency medical services programs at Oregon Health and Science University and the Oregon Institute of Technology, led the research, which was presented in December at the Institute for Healthcare Improvement Scientific Symposium in Orlando, Fla.

The researchers received a grant to produce the internal report for the Oregon Emergency Medical Services department and the Oregon Office of Rural Health.

Outright discrimination by paramedics is rare, the researchers say, and illegal; in these cases, unconscious bias may be at work.

A few years ago, Leslie Gregory was one of a very few black female emergency medical technicians working in Lenawee County, Mich. She said the study’s findings ring true based on her experience.

She remembered one particular call — the patient was down and in pain. As the EMTs arrived at the scene, Gregory could see the patient was black. And that’s when one of her colleagues groaned.

“I think it was something like: ‘Oh, my God. Here we go again,’” Gregory said. She worried — then, as now — that because the patient was black, her colleague assumed he was acting out to get pain medication.

“I am absolutely sure this was unconscious,” added Gregory, who now lives and works in Portland, Ore., where she founded a nonprofit to spread awareness about racial disparities in health care. “At the time, I remember, it increased my stress as we rode up on this person. Because I thought, ‘Now am I going to have to fight my colleague for more pain medication, should that arise?’”

Leslie Gregory, a Portland physician assistant, asks, “How can a person of color not disrespect a system that is constantly studying and talking about these disparities, but does nothing to fix it?” She wants the CDC to declare the effects of racism a national health crisis.(Kristian Foden-Vencil/Oregon Public Broadcasting)

Unconscious bias can be subtle — but, as this new report shows, it may be one of the factors behind race-linked health disparities seen across the U.S.

The study looked at 104,000 medical charts of ambulance patients from 2015 to 2017. It found that minority patients were less likely to receive morphine and other pain medication compared with white patients — regardless of socioeconomic factors, such as health insurance status.

During a shift change at American Medical Response headquarters in Portland,  EMTs and paramedics discussed the issue with a reporter as they got their rigs ready for the next shift.

Jennifer Sanders, who has been a paramedic for 30 years, was adamant that her work is not affected by race.

“I’ve never treated anybody different — regardless,” said Sanders.

Most of the emergency responders interviewed, including Jason Dahlke, said race doesn’t affect the treatment they give. But Dahlke also said he and some of his co-workers are thinking deeply about unconscious bias.

“Historically it’s the way this country has been,” Dahlke said. “In the beginning, we had slavery and Jim Crow and redlining — and all of that stuff you can get lost in on a large, macro scale. Yeah. It’s there.”

Paramedic Jason Dahlke says he can see how unconscious bias could slip into an emergency responder’s decisions and taint health care. He’s worked hard to be aware of it, in hopes of preventing those disparities in care.(Kristian Foden-Vencil/Oregon Public Broadcasting)

Asked where he thinks unconscious bias could slip in, Dahlke talked about a patient he just treated.

The man was black and around 60 years old. Dahlke is white and in his 30s. The patient has diabetes and called 911 from home, complaining of extreme pain in his hands and feet.

When Dahlke arrived at the patient’s house, he followed standard procedure and gave the patient a blood glucose test. The results showed that the man’s blood sugar level was low.

“So it’s my decision to treat this blood sugar first. Make sure that number comes up,” Dahlke said.

He gave the patient glucose — but no pain medicine.

Dahlke said he did not address the man’s pain in this case because by the time he had stabilized the patient they had arrived at the hospital — where it was the responsibility of the emergency department staff to take over.

“When people are acutely sick or injured, pain medication is important,” Dahlke said. “But it’s not the first thing we’re going to worry about. We’re going to worry about life threats. You’re not necessarily going to die from pain, and we’re going to do what satisfies the need in the moment to get you into the ambulance and to the hospital and to a higher level of care.”

Dahlke said he is not sure whether, if the patient had been white, he would have administered pain medicine, though he doesn’t think so.

“Is it something that I think about when I come across a patient that does not look like me? I don’t know that it changes my treatment,” he said

Asked whether treatment disparities might sometimes be a result of white people being more likely to ask for more medications, Dahlke smiled.

“I wonder that — if, in this study, if we’re talking about people of color being denied or not given narcotic medicines as much as white people, then maybe we’re overtreating white people with narcotic medicines.”

Research has found African-Americans more likely to be deeply distrustful of the medical community, and that might play a role in diminished care, too. Such distrust is understandable and goes back generations, said Gregory.

“How can a person of color not disrespect a system that is constantly studying and talking about these disparities, but does nothing to fix it?” she asked.

Gregory wrote an open letter to the Centers for Disease Control and Prevention in 2015, asking it to declare racism a threat to public health.

Past declarations of crisis — such as those focusing attention on problems such as smoking or HIV — have had significant results, Gregory noted.

But the CDC told Gregory, in its emailed response, that while it supports government policies to combat racial discrimination and acknowledges the role of racism in health disparities, “racism and racial discrimination in health is a societal issue as well as a public health one, and one that requires a broad-based societal strategy to effectively dismantle racism and its negative impacts in the U.S.”

Kennel said false stereotypes about race-based differences in physiology that date to slavery also play a role in health care disparities. For example, despite a lack of any supporting science, some medical professionals still think the blood of African-Americans coagulates faster, Kennel said, citing a recent study of medical students at the University of Virginia.

Another question in the survey asked the students whether they thought African-Americans have fewer pain receptors than whites. “An uncomfortably large percentage of medical students said, ‘Yes, that’s true,’” said Kennel.

On top of that, he said, EMTs and paramedics often work in time-pressured situations, where they are limited to ambiguous clinical information and scarce resources. “In these situations, providers are much more likely to default to making decisions [based] on stereotypes,” he said.

Disparities in health care are well-documented. Whites tend to get better care and experience better outcomes, whether they’re in a doctor’s office or the ER. But before Kennel’s study, nobody knew whether the same was true in the back of an ambulance.

And they nearly didn’t get to know, because the research required ambulance companies to release highly sensitive data.

“We were prepared to maybe not look that great,” said Robert McDonald, the operations manager at American Medical Response in Portland. AMR is one of the nation’s largest ambulance organizations, and it shared its data from more than 100,000 charts with Kennel.

Some people chalk up the disparities he found to differences in demography and health insurance status, but Kennel said he controlled for those variables.

So now that AMR knows about disparities in its care, what can the company do?

“My feeling is we’re probably going to put some education and training out to our folks in the field,” McDonald said.

In addition, he said, AMR is going to hire more people of color.

“We want to see more ethnicities represented in EMS — which has historically been a white, male-dominated workforce,” McDonald said.

AMR’s policies must change, too, he added. The company has purchased software that will enable patients to read medical permission forms in any of 17 different languages. And the firm is planning an outreach effort to communities of color to explain the role of EMS workers.

This story is part of a partnership that includes Oregon Public BroadcastingNPR and Kaiser Health News.

Innovative App Would Detect Opioid Overdoses, Developers Say. Would People Turn It On, Though?

Researchers tested the experimental gadget at North America’s first supervised injection site in Vancouver, British Columbia, and found it correctly identified breathing problems. Other news on the opioid crisis focuses on a call for more federal funding, a dismissal of lawsuits against Purdue Pharma, attempts to measure pain, a deadly new mix of drugs and more.

Johnson & Johnson CEO Warns That Pharma Should Police Itself Over Drug Prices As Other Options Could Be ‘Onerous’

“If we don’t do this as an industry, I think there will be other alternatives that will be more onerous for us,” Johnson & Johnson CEO Alex Gorsky said at the J.P. Morgan Healthcare Conference in California. Drug pricing was just one of the many topics that were being hotly discussed at the annual event that draws the movers-and-shakers in the industry.

Flurry Of Movement On Capitol Hill On Drug Pricing May Signal Possible Rough Waters Ahead For Pharma

Sen. Chuck Grassley (R-Iowa) was one of a handful of lawmakers who have introduced legislation to curb high drug costs in the first few weeks of Congress being back in session. The topic is seen as one of only a few bipartisan issues that may get addressed by a divided Congress this year. In other pharmaceutical news, government officials are worried that drugmakers are using scare tactics to keep competition out of the marketplace.

Some States Mull A Medicaid ‘Buy In’ As More Palatable Solution To Politically Polarizing ‘Medicare For All’ Plans

States have begun exploring the possibility of a Medicaid “buy in” as an attractive option for people who are struggling to find affordable coverage. With the strategy comes a plethora of questions, though, such as, who would be eligible and what benefits would be offered.

Extreme Temperatures May Pose Risks To Some Mail-Order Meds

Take a look at your prescription bottles. Most say “Store at room temperature” or “Keep refrigerated.”

But what happens when drugs are delivered by mail? Were those instructions followed as the medicine wended its way from the pharmacy to your doorstep?

Those questions haunt Loretta Boesing, who lives in Park Hills, a small town in the hills of eastern Missouri, where the weather varies dramatically from season to season.

“It’s crazy,” Boesing said. “We sometimes experience temperatures like they would feel in Arizona. Sometimes we experience temperatures like they would feel up north.”

In 2012, when son Wesley was 2 years old, he got so sick from the flu that he needed a liver transplant.

The transplant surgery went well, but just a few months later, lab tests showed Wesley’s body appeared to be rejecting the organ.

Boesing felt both devastated and guilty.

“I feel the extra duty of not just protecting his life, but the life that lives on inside him,” she said.

Wesley didn’t lose his new liver, but during his weeks in the hospital, Boesing’s mind raced, thinking about what might have gone wrong.

She remembered that when his anti-rejection medications were last delivered to their house, the box had been left outside by the garage, where it sat for hours.

Temperatures that day were well over 100 degrees, well beyond the safe temperature range listed on the drug’s guidelines.

At the time, she hadn’t worried about it.

“Even though I see plainly on the bottle that it says, ‘Store at room temperature,’” Boesing said, “I still thought, ‘Ah, someone’s making sure it’s safe.’”

But after Wesley’s setback, Boesing swore off mail-order pharmacy altogether, and this year she started a Facebook group for patients who share her concerns about how extreme temperatures during shipping could affect the prescription drugs that many people receive by mail.

As of 2016, prescriptions fulfilled by mail accounted for nearly a quarter of total U.S. spending on prescriptions (before rebates and discounts), according to a report from IQVIA’s Institute for Human Data Science.

Health insurers typically contract with companies known as pharmacy benefit managers to handle the complex process of getting medicine to patients. PBMs negotiate with drugmakers on prices and rebates, help insurers decide which drugs to cover and handle mail-order shipping.

Mail order is a money saver for PBMs, and, in turn, they’ve touted the potential advantages for patients — such as 90-day refills for the cost of a 30-day copay, and the added convenience, especially for rural or housebound patients.

But Boesing wants insurers and their PBMs to reconsider these incentives and their practices in light of temperature concerns. She says they must ensure that their patients have easy access to retail pharmacies — unless the mail-order services can prove that drugs are getting to patients at the right temperatures.

The three biggest PBMs are Express Scripts, CVS Caremark and OptumRX. They insist they’ve got mail-order drug shipment down to a science.

Inside an enormous OptumRX warehouse in a Kansas City suburb, lines of orange prescription bottles fly along conveyor belts, while pharmacists scan bar codes and technicians refill bins of pills.

Lead pharmacist Alysia Heller explains that this shipping behemoth, which sends out as many as 100,000 prescriptions a day, includes a system to account for weather.

“If there’s an extreme heat situation where a product is going into 100-plus-degree weather, the system will tell the technician to add an extra ice pack,” Heller said, “because we’ve monitored the ZIP code and the weather in that area.”

But at OptumRX and across the industry, that level of temperature-controlled shipping is usually reserved only for a relatively small number of drugs — such as certain types of insulin, or hepatitis C drugs that have specific refrigeration requirements.

Standard, room-temperature medications (like most drugs for blood pressure or cholesterol, which make up the vast majority of prescriptions shipped) are typically sent in bubble mailers without any temperature monitors.

Stephen Eckel, a pharmacy professor at the University of North Carolina at Chapel Hill, said those practices can lead to some drugs being damaged.

“A lot of people enjoy the convenience of mail order, but there are some risks they’ve got to understand,” said Eckel. He said it’s possible that drugs in liquid form, such as the one Wesley was taking, could potentially be damaged by exposure to extreme heat or cold.

He predicts it’s just a matter of time before mail-order pharmacies will expand their use of temperature controls and add individual temperature monitors to all packages, so customers can see whether their medications got too hot or too cold in transit.

But Adam Fein, a consultant on pharmaceutical economics and drug distribution, called the temperature concerns overblown. He pointed out that many states already require insurance companies and/or PBMs to offer access to retail pharmacies if customers prefer.

“We have literally billions and billions of prescriptions that have been dispensed by mail over many years without evidence of widespread harm,” Fein said.

The Pharmaceutical Care Management Association is a national trade industry group for PBMs. In response to questions about temperature concerns and the safety of mail-order drugs, the association wrote in a statement: “Mail-service pharmacies adhere to all Food and Drug Administration rules, ship those prescription medications that may be adversely affected by extreme heat in refrigerated packaging, and notify patients to make sure those packages have been delivered properly.”

Some room-temperature drugs are approved to spend up to 24 hours in temperatures from as low as the upper 50s to as high as 104 degrees. But scientists just don’t know how a number of medications respond to more extreme temperatures — such as they might experience on a freezing porch or in the back of a sweltering truck.

A few studies suggest that some inhalers or antibiotics can lose potency over time.

Many industry experts think mail-order pharmacy is on the cusp of a boom driven by the development of new specialty drugs, especially biologics. Many of those often come with a hefty price tag and are generally not handled by retail pharmacies. These specialty drugs, many of which are injected, can be more vulnerable to temperature swings.

Competition in the mail-order drug industry is heating up, with Amazon’s acquisition last summer of online pharmacy PillPack, and the announcement in December that Walgreens would work with FedEx to offer next-day medication delivery.

Fein said more temperature controls and monitoring would do little more than drive up costs in an industry that’s been successful in large part because of its low operating costs.

But after collecting more than 76,000 signatures for an online petition on the issue, Loretta Boesing said she’s convinced a larger health problem is being shrugged off.

In Missouri, the Board of Pharmacy has decided to review its mail-order prescription policies and invited Boesing to testify.

Her son still needs prescriptions, but Boesing has stopped using Walgreens’ Specialty Pharmacy, which was shipping the drugs. She obtained a waiver that lets her fill Wesley’s prescriptions at a specialized pharmacy affiliated with a children’s hospital in St. Louis. She makes the two-hour round-trip drive every month to pick up the medicine.

After connecting with patients all over the country, she said, her advocacy is no longer just about keeping Wesley safe.

“I don’t want my son to have to receive special treatment,” Boesing said. “I want everyone to have access to safe medications.”

This story is part of a partnership that includes KCUR, NPR and Kaiser Health News.


KHN’s coverage of these topics is supported by
Laura and John Arnold Foundation
and
Heising-Simons Foundation

Medical Marketing In The U.S. Has Boomed Over Past Two Decades–With Meager Oversight To Keep It In Check

A new analysis of marketing data from the FDA, Medicare, other federal and state agencies, private companies and medical research finds a 69 percent increase, to $29.9 billion, over a recent 20-year period. “Marketing drives more treatments, more testing” that patients don’t always need, said Dr. Steven Woloshin, a Dartmouth College health policy expert.

As Pharma Returns To Status Quo On Drug Prices, Trump Meets With Top Advisers To Discuss Frustrations

“The president’s been really clear — prices of drugs need to be coming down, not going up,” said HHS Secretary Alex Azar, who was reportedly a part of the meeting. Meanwhile, Democrats on Capitol Hill are looking to score some early wins with small drug pricing legislation.

Every NYC Resident To Be Guaranteed Health Coverage As Part Of Mayor’s Expanded $100 Million Plan

The NYC Care plan, which Mayor Bill de Blasio said would be funded without tax increases, is an expansion of the city’s existing MetroPlus plan that covers hospital bills for low-income residents. “No one should have to live in fear. No one should go without the health care they need. Health care is a human right. In this city, we’re gonna make that a reality,” de Blasio said during a news conference. The plan would also cover immigrants who are living in the country illegally. Meanwhile, Washington Gov. Jay Inslee announced plans to offer residents a public option which would be a step toward single-payer health care.

Health Care Industry Spends $30B A Year Pushing Its Wares, From Drugs To Stem Cell Treatment

Hoping to earn its share of the $3.5 trillion health care market, the medical industry is pouring more money than ever into advertising its products — from high-priced prescriptions to do-it-yourself genetic tests and unapproved stem cell treatments.

Spending on health care marketing doubled from 1997 to 2016, soaring to at least $30 billion a year, according to a study published Tuesday in JAMA.

“Marketing drives more testing. It drives more treatments. It’s a big part of why health care is so expensive, because it’s the fancy, high-tech stuff things that get marketed,” said Steven Woloshin, co-director of the Center for Medicine and Media at The Dartmouth Institute for Health Policy and Clinical Practice. His study captured only a portion of the many ways that drug companies, hospitals and labs promote themselves.

Advertising doesn’t just persuade people to pick one brand over another, said Woloshin. Sophisticated campaigns make people worry about diseases they don’t have and ask for drugs or exams they don’t need.

Consumer advocates say that taxpayers pay the real price, as seductive ads persuade doctors and patients alike to order pricey tests and brand-name pills.

“Whenever pharma or a hospital spends money on advertising, we the patients pay for it — through higher prices for drugs and hospital services,” said Shannon Brownlee, senior vice president of the Lown Institute, a Brookline, Mass., nonprofit that advocates for affordable care. “Marketing is built into the cost of care.”

High costs ultimately affect everyone, because they prompt insurance plans to raise premiums, said Diana Zuckerman, president of the National Center for Health Research, a nonprofit that provides medical information to consumers. And taxpayers foot the bill for publicly funded insurance programs, such as Medicare.

“These ads can be amazingly persuasive, and they can exploit desperate patients and family members,” said Zuckerman, who was not involved in the new study.

Drug companies spend the bulk of their money trying to influence doctors, showering them with free food, drinks and speaking fees, as well as paying for them to travel to conferences, according to the study.

Dr. Lisa Schwartz and Dr. Steven Woloshin(Courtesy of the Dartmouth Institute for Health Policy & Clinical Practice)

Yet marketers also increasingly target consumers, said Woloshin, who wrote the study with his wife and longtime research partner, Dartmouth’s Dr. Lisa Schwartz, who died of cancer in November.

The biggest increase in medical marketing over the past 20 years was in “direct-to-consumer” advertising, including the TV commercials that exhort viewers to “ask your doctor” about a particular drug. Spending on such ads jumped from $2.1 billion in 1997 to nearly $10 billion in 2016, according to the study.

A spokeswoman for the pharmaceutical industry group, PhRMA, said that its ads provide “scientifically accurate information to patients.” These ads “increase awareness of the benefits and risks of new medicines and encourage appropriate use of medicines,” said Holly Campbell, of PhRMA.

The makers of genetic tests — including those that allow people to learn their ancestry or disease risk —also bombard the public with advertising. The number of ads for genetic testing grew from 14,100 in 1997 to 255,300 in 2016, at a cost that year of $82.6 million, according to the study. AncestryDNA spends more than any other company of its kind, devoting $38 million to marketing in 2016 alone.

Some companies are touting stem cell treatments that haven’t been approved by federal regulators. The Food and Drug Administration has approved stem cell therapy for only a few specific uses — such as bone marrow transplants for people with leukemia. But hundreds of clinics claim to use these cells taken from umbilical cord blood to treat disease. Many patients have no idea that these stem cell therapies are unapproved, said Angie Botto-van Bemden, director of osteoarthritis programs at the Arthritis Foundation.

Stem cell clinics have boosted their marketing from $900,000 in 2012 to $11.3 million in 2016, according to the study.

In recent months, the FDA has issued warnings to clinics marketing unapproved stem cell therapies. Twelve patients have been hospitalized for serious infections after receiving stem cell injections, according to the Centers for Disease Control and Prevention.

Medical advertising today goes beyond TV and radio commercials. Some online campaigns encourage patients to diagnose themselves, Woloshin said.

The website for Restasis, which treats dry eyes, prompts patients to take a quiz to learn if they need the prescription eye drops, said Woloshin, who co-wrote a February study with Schwartz on the drug’s marketing strategy. The Restasis website also allows patients to “find an eye doctor near you.”

Many of the doctors included in the Restasis directory have taken gifts from its manufacturer, Allergan, Woloshin said. The doctor directory includes seven of the top 10 physicians paid by the company, his study says.

In a statement, Allergan spokeswoman Amy Rose said the company uses direct-to-consumer advertising “to support responsible disease awareness efforts.” The ads “do not displace the patient-physician relationship, but enhance them, helping to create well-informed and empowered consumer and patient communities.”

Drug sites don’t just lead patients to doctors. They also provide scripts for suggested conversations. For example, the website for Viagra, which treats erectile dysfunction, provides specific questions for patients to ask.

The website for Addyi, often called the “female Viagra,” goes even further. Patients who answer a number of medical questions online are offered a 10- to 15-minute phone consultation about the drug for $49. Patients who don’t immediately book an appointment receive an email reminder a few minutes later.

“This is more evidence,” Brownlee said, “that drug companies are not run by dummies.”