June 30th, 2009 by KerriSparling in Better Health Network, Humor, True Stories
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Last night after work, I stopped by the grocery store to pick up a few things on my way home. The place was post-work packed.
I was wearing a dress with a bit of a busy print, and loud, clacking heels, so I wasn’t really a shrinking violet. But it wasn’t a big deal to be a bit over-dressed for grocery shopping - I was just running in and running out as quickly as I could.
I go to the produce section and fill my cart with a few items, then I remember that Chris asked me to get fruit. So I went over to the selection of apples, which had apparently just been refilled, as they were piled high. High as in like two dozen levels of red, shiny apples. With a plastic bag in my hand, I reached out and grabbed an apple. And then another.
And then I reached for a third.
Which must have been precariously placed.
As every apple in the stack came tumbling towards me. Like in a cartoon.
“OOOOH!” I yelled, whipping my arms around like a windmill in effort to stop the avalanche.
“OOOOH!” I yelled, as I pressed myself against the side of the shelving to keep the apples from hitting the floor, letting them pile up against me instead.
“OOOOH!” I yelled as the apples created a slope against my body and then starting falling faster from the tower, rocketing off my shoulder and flying high into the air.
“OOOOH!” The woman a few feet away yelled, as an apple ricocheted off the shelving and landed in her cart.
I was dying of embarrassment. The apples were hitting the floor with a loud thunk and people were staring and the grocery store produce guys were running over, trying to help, but their laughter rendered them useless.
“Oh my God, please make this stop. Please, can you just make the apples stop their onslaught!” I pleaded, my arms filled with fruit.
The produce guy closest to me tried to stem the flow of apples, but it was fruitless. These apples were powered by inertia and determined to make a spectacle of me.
“Miss, you need to step away from the apples so we can clean them up. Can you move back a few steps?”
“If I move, all the ones I’m holding will fall. And then I will die of shame.” I tried to talk without moving my mouth, as to not further enrage the apples.
The produce guy tried to hide his laughter. “Miss, step away from the apples. I’m ready to deal with them. In three … two … one …”
I moved back and all the apples I was holding in my arms tumbled to the ground with a SMACK. A sea of large, red marbles on the tile floor. My face was as red as an … well, you can guess.
“Can I help you clean up? Or can I go? Can I just walk away and pretend this didn’t happen?”
“Run, lady. You might want to run.”
I fumbled for my purse and my grocery cart and tried to eek away gracefully (as gracefully as one can, with loud heels and a noticeable dress), turning my ankle on an apple only once. People were smirking and laughing, and one old man started to applaud.
I left the grocery store, my face on fire and laughing to myself. I called my mother from my car and told her the story through my embarrassment and tears of laughter.
“I think I’m channeling Grammie,” I said.
“Oh Kerri … you’re right,” my mother laughed. “Grammie was known for wearing platform shoes in the grocery store and falling over at the deli counter. And you know what? I wore platform shoes to the deli counter when I was your age and I fell over, too! It’s hereditary!”
Note to self: Do not buy platform shoes.
*This blog post was originally published at Six Until Me.*
June 30th, 2009 by Medgadget in Better Health Network
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Wooden legs sure have come a long way since they were first used as artificial prostheses. In the latest issue of Journal of Materials Chemistry, there is a report on the recent developments at the Institute of Science and Technology for Ceramics in Italy in which scientists have turned wood into something similar to bone, a material that may one day be used to create custom replacement parts.
Researchers heated the wood to decompose organic material to leave only the carbon template. Then, they reacted the template with calcium, oxygen, and carbon dioxide to form calcium carbonate that was then converted to hydroxyapatite. This hydroxyapatite scaffold mimics the structure of bone. The advantage of this process is the architectural make-up of the wood’s structure that affords the ability of cells and blood vessels to grow through it, much like real bone.
‘Current [hydroxyapatite] production processes do not generate an organised hierarchical structure,’ says Anna Tampieri. ‘Materials able to maintain adequate properties at extremely high temperatures and mechanical stress are highly sought after for use in several different applications, such as space vehicles. An intriguing possibility is that of simultaneously achieving high values of strength and toughness, for which ordinarily there is a trade-off. In addition, new materials with extreme physical properties, such as thermal expansion or piezoelectricity, can be obtained.’
More from the Journal of Materials Chemistry : Trees take on tissue engineering; From wood to bone: multi-step process to convert wood hierarchical structures into biomimetic hydroxyapatite scaffolds for bone tissue engineering…
*This blog post was originally published at Medgadget*
June 30th, 2009 by DrRob in Better Health Network, Humor
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Yes, it’s time for another installment of my series on the physical exam. The goals of this series are:
- To educate my readers on the intricacies of the physical exam.
- To teach the anatomy and physiology as it relates to different parts of the human body.
- To delight my readers with my wit and fine prose.
- World peace.
So you see, through my hard work and persistence (writing almost 30,000 words about the physical exam so far), I have come nowhere near any of these goals. In fact, I have made absolutely no progress toward world peace. I think I’ve been banned in Iran for using the word “Shuttlecraft” too many times.
Maybe I just need some new goals. How about these:
- To irritate my high school English teachers.
- To cause at least 200 people to waste time that they could have spent watching Oprah.
- To make sure Canada stays north of us and does not sneak to Florida.
- To put those pesky French people in their place.
Yes, I think those are much better goals.
Extremely Upper
Our journey over the human body has now led us to the long things that stick out of the top of your torso that have those grabby things on the ends. We doctors call these things arms. There are some hoity-toity doctors who call them the upper extremities. These are the doctors you don’t want to invite to dinner, as they will probably tell you disgusting scientific facts about the food you are eating. Consider yourself warned.
The exam of the arms is usually only referred to vaguely during routine exams. Most docs don’t deal with the arms unless they pick up subtle clues that are discovered only by trained professionals, like when the patient says “I’m having problem with my arms”. We doctors are proud of our mad skills.
What I am driving at is that the arm exam is a problem-oriented exam. If you have a boo-boo, the doctor looks at it and sees if a kiss will make it better. If a kiss doesn’t work, usually an anti-inflammatory will (but we’ll get to that later). And boo-boo problems with the arm are usually specific to the longitude and latitude on the body. So today we will discuss the shoulder.
The Shoulder
The shoulder is a joint – meaning, it is a place where your body bends. Without joints, your arms would be unwieldy and you’d whack everyone who came near to you. Not only that; it would also make it impossible to put on deodorant. So between whacking people and offending them with your odor, a jointless existence would truly be a hard one. We all should thank our joints more often.
There is not a more complex joint in your body than your shoulder. Here are some amazing facts about the shoulder:
- There are three bones that are involved in different types of movement: the collarbone (clavicle), shoulder blade (scapula), and humerus (not humorous).
- There are at least 18 muscles that are involved in shoulder movement. Two of them have the word “rhomboid” in them. I like the word “rhomboid.”
- When people say the word “shoulder,” they may be referring to the joint, and they could be referring to the top part of their torso – between their neck and shoulder joints. This is a sad testimony to the English language and just serves to make the jobs of medical professional all the harder.
- The word “shoulder” rhymes with a lot of of words and so is very useful in poetry. For instance:
You shouldn’t have told her that she’s looking older
She wants you to hold her with arm on her shoulder
And go get the folder that llamas once sold her
But there on the boulder the weather is colder.
A fine Jell-O mould or perhaps something bolder
Has rocked her and rolled her but never controlled her
So anger may smolder at cellular slime mold or
Other thingies, sort of.
See? Pretty amazing, isn’t it? Try doing that with “elbow!” Perhaps Dino could write a haiku about it.
So it should not be seen as a coincidence that the shoulder has by far the largest range of motion of any of the joints in the body. This makes things very confusing for medical students when they have to describe the motion, as the joint doesn’t follow any of the rules the other joints have agreed upon. Most joints can be bent (flexed) and straightened (extended). Some joints (like the wrist) can be hyperextended and rotated as well. All the other joints are content with these motions. Is this good enough for the shoulder? Not even close.
Here are the basic movements of the shoulder:
1. Flexion – moving the arm forward toward the chest.
2. Extension – moving the arm toward your back.
3. Abduction – Being picked up by aliens and brought to their mother ship. (This also refers to lifting your arms up from your sides).
4. Adduction – Bringing your arms down back to your sides
5. Rotation – Turning the arm around the axis of the humerus bone.
I have suggested a few more motions that may be added to the roster:
6. Subflaxion – What you have to do to your shoulder to get your elbow in your ear.
7. Soufflétion – When your shoulder is mixed with eggs and baked at 400 degrees.
8. Mallardduction – When your shoulder gets down.
So far the shoulder committee hasn’t answered my mail. I’m not sure why.
But really, the shoulder is very confusing to many medical professionals. The range of motion is so great that it blurs the lines between the typical movements. For instance, adduction is supposed to be when the limb is moved toward the body’s midline. The shoulder makes this difficult. When you put your arm by your side and when you raise it over your head, you move it toward midline. Both could be considered adduction. The same is true with flexion and extension – when is the shoulder joint opened up and when is it closed?
Really, in this modern time we should give up this archaic nomenclature and instead use a GPS device to determine shoulder position.
Wow. 1000 words already and I haven’t gotten to the actual exam. I’ll give it a rest now and let you ruminate on words that rhyme with “elbow.”
I probably should sober up as well.
*This blog post was originally published at Musings of a Distractible Mind*
June 30th, 2009 by Happy Hospitalist in Better Health Network, Opinion
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The drug makers have agreed to cover part of the costs of brand name drugs in the donut hole, that no man’s land of Medicare Part D where patients must pay for their own drugs.
As reported:
Obama said that drug companies have pledged to spend $80 billion over the next decade to help reduce the cost of drugs for seniors and pay for a portion of Obama’s health care legislation. The agreement with the pharmaceutical industry would help close a gap in prescription drug coverage under Medicare.
I see one problem with the assertion that drug companies will be “spending” $80 billion dollars to reduce the cost of drugs for seniors. Drug companies and by default, their board of directors have allegiance to their shareholders, not the the US government or the seniors of this country. I can assure you, this deal may look good on paper (for seniors) and it may benefit seniors a great deal (FREE=MORE) but it is also one step further to the promised land of the senior vote. And it will worsen access to drugs for everyone else. There is no free lunch in this world.
It may save seniors money, but it will not be revenue neutral. It will not save $80 billion dollars over 10 years or reduce overall costs of care. Somehow, someway, the costs will be shifted. It may mean higher drug costs for those privately insured or the uninsured. It may mean decreased access to compassion programs. It may mean higher costs to hospitals. Whatever the agreement means, it will not mean $80 billion dollars saved in the next decade.
Drug companies are not in the business of sacrificing their shareholders or bond holders for patriotic means. They are in the business of making money. And that means they have selfish interests to maximize their ROI for any agreement they make with the government.
The question isn’t really how wonderful this is for seniors. The question is how will buying off seniors affect the rest of America. And I’m telling you here, right now, you will see higher costs for everyone not lucky enough to bathe in a sea of FREE=MORE known as the Medicare National Bank.
*This blog post was originally published at A Happy Hospitalist*
June 29th, 2009 by DrNancyBrown in Better Health Network, Health Tips
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After you get over the urge to run and hide, lock your teen in the bathroom, shave his or her head, and save yourself, take a deep breath and think about what is important here. You are likely panicked because you know that sooner or later someone will break your teens heart - and there is nothing you can do about it, or is there?
Talk to your teen and share what you are feeling as well as what you know. Being new to the world of love/lust/hormones, there are some really great conversations to be had now about balance, friendship, and healthy relationships! First, your teen may be overwhelmed with how wonderful it feels to be in love and you can help remind your teen about balance, and the importance of not losing themselves for love. Your teen needs to stay “true to self” instead of becoming an appendage to the new love. Encourage your teen to stay connected to friends, school, outside activities, family, and sports, while making room for the new love.
You might mention that if that becomes an issue, you can help by setting limits on the amount of hanging out at home, phone, text, and computer time, to help her learn to balance life and love/lust/hormones. This is not a threat - just a supportive way to help your teen transition in the world of love!
Together you can set the expectations that honor this new part of life, make your teen feel listened to and involved with the new contract - the new couple spends time with the family, grades stay up, activities continue, chores, whatever else her life includes must all continue - because your teen has to be a “person” first before a girlfriend or boyfriend. The We’re Talking web site has a great section called the abcs of healthy relationships, which will provide many reminders about knowing when a relationship is not healthy.
Along those same lines, it is important to talk about the importance of friendship - and how you want the first few months together to be spent with family - because early in relationships the goal is to learn to trust each other, find things that you have in common, and become parts of each others lives. Friendship is stronger in the long run than hormones - and if either member of the couple is motivated by anything else other than love - s/he will not make it through the “getting to know all about you” phase.
P.S. Remember that the greater the age difference, and the more time alone they share, the more likely teens will take new love to sexual realms, so be aware and good luck!
This post, When Your Teen Starts Dating, was originally published on
Healthine.com by Nancy Brown Ph.D..
June 29th, 2009 by Shadowfax in Better Health Network, Opinion
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Surgery Residency, Massachusetts General Hospital and Work Limits - Health Blog - WSJ
It’s not surprising that newly minted doctors at one of the most prestigious hospitals in the country, and in a specialty with a particularly demanding residency, have been violating national limits on work hours.
But the Boston Globe’s report that Massachusetts General Hospital must rein in surgical residents’ hours is a reminder that the work limits put in place several years ago remain unpopular with many residents and senior doctors.
Not surprising in the least. I’m actually astonished that there’s anybody with the chutzpah to defend extended work hours for residents. I did my residency largely in the pre-hour-restriction era — there were hour restrictions on months in the ER, but effectively none for the off-service rotations — and it was a terrible way to deliver care. I did my time of q3 call in the units and q2 call on surgical services. This includes a memorable time when I was the sole intern on the pediatric surgical service and was on duty for ten days straight without leaving the hospital. That gives a new meaning to being a “resident physician!” (Actually, that’s the original meaning, if you must get picky about it.)
The care provided was just scary. I prided myself on being a machine and able to get through 36 hours of uninterrupted work without cracking; I used to run marathons and endurance was my forte. And I did get through it better than most. But after 24 hours with no down time (and there was never meaningful down time), you get stupid, and you make mistakes. I remember once, in the medical ICU I was surprised in morning rounds to find that one of my patients had had a swann-ganz catheter placed overnight. Caught flat-footed by this in front of the attending, I asked the nurse who had put in a swann without telling me, only to be informed that I had done the procedure! Apparently I was too sleep-addled to recall that I had done it! Fortunately, I had apparently done it right, because a swann involves threading a catheter through the heart into the pulmonary vessels and can be Very Bad [tm] if you screw it up. But I apparently did it by reflex without actually achieving a state of full wakefulness. This sort of thing was fairly routine, and I also remember well the overnight residents being excoriated in morning rounds for the errors and misjudgments they had made overnight. Great training, but not so great for the patients who were the victims of the mistakes.
It seems to me that the defenders of the status quo have donned their rose-colored glasses. They fondly remember the camaraderie and the pride in accomplishment that their residencies evoked, while conveniently forgetting the mistakes and omissions, while neglecting the depression and divorces and other personal costs of such an abusive training environment. And there’s the faux toughness: “I got through it, they can, too if they’re not too weak.” And the old guard romanticize the qualities of the “true physician” in their dedication to their patients above all else: “These younger doctors just don’t care enough.”
What a load of crap.
Look, it’s with damn good cause that other professions in which errors can hurt people have work time restrictions (truck drivers, airline pilots, etc), and it’s stupid and arrogant to think that we physicians are so awesome that we are immune to the human factors of fatigue and circadian rhythms that contribute to errors. When it’s inexperienced trainees working the ridiculous hours with minimal supervision (in many cases), the potential for fatigue-related errors is compounded.
I also question the motivations of some of those who defend the status quo. It seems strangely self-serving that residency directors who would otherwise have to find attending physicians or PAs to perform the work that residents do on the government’s dime are the ones to insist that the situation is just fine, or that “the evidence of benefit is lacking.” How cool is it that they can ignore reams of research on human factors, take the a priori position that the system is fine as it is, and demand formal evidence on “efficacy, safety and cost” before making any changes? That’s balls! It’s also fairly blatant obstructionism and should not be given any credence.
Dr Bob of Medrants has some thoughtful comments on the matter, mostly pleading for flexibility in the new rules. I would mostly agree, excepting that flexibility is best given to those who have proven themselves trustworthy, and residency directors (especially but not exclusively of surgical training programs) have repeatedly and flagrantly flouted the rules thus far imposed. Flexibility is fine, but accountability should also be demanded.
I would also take issue with Dr Bob’s comment that this “training system that has served our profession well for many years.” I look at the statistics on physician burnout, substance abuse, divorce, depression and suicide. They are terribly concerning. I would not lay all of this at the feet of residency, but I would say that the abusive (I’m sorry, “rigorous”) environment of residency training sets the tone for the culture of machismo that harms physicians as much as it harms patients. Nobody is well-served by the current system.
It is true that change might be painful. Reducing hours might mean reducing patient contacts and reducing the training opportunities for physicians. This might require academic centers to revalue the time of physicians in training, by which I mean that residents might no longer be used as free menial laborers. Maybe it doesn’t make sense to have a surgical resident “running the book” — many surgical residents never see the inside of the OR till their second and third years. The universities might have to hire PAs or NPs for the “scut work” instead of using MDs in training as glorified secretaries (what a waste of time and money).
I’m glad the Institue of Medicine and the ACGME seem to be on the right path with the recommendations. The reactionary response from the change-resistant academic centers will take some time and political will to overcome. I remember when they first imposed the rules, they followed it up by decertifying the Internal Medicine program at Hopkins for violating the rules. That effected the desired change, I can tell you! Hopefully, as the restrictions evolve, there will be accountability and enforcement until the culture starts to shift.
*This blog post was originally published at Movin' Meat*
June 29th, 2009 by admin in Better Health Network, Health Policy
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Much has been made of the recent pressure on the FDA to create a pathway for follow-on biologics. On June 9, 2009, Rep. Henry Waxman, chair of the Energy and Commerce committee, sent a letter to President Obama imploring him to approve a pathway for generic biologics: “I urge the administration to consider what steps can be taken under existing authority to prepare and even begin to use a pathway for generic biologics.”
Six days later, President Obama, in his June 15, 2009 speech to the AMA, followed Waxman’s lead, asking the FDA and industry “to introduce generic biologic drugs into the marketplace.” He continued: “These are drugs used to treat illnesses like anemia. But right now, there is no pathway at the FDA for approving generic versions of these drugs. Creating such a pathway will save us billions of dollars.”
Is this true? Are follow-on biologics, biosimilars, or generic biologics (all names for the same concept) truly the path to healthcare savings? And what are they, anyway? To clear up the confusion, this post aims to explain what biologics are, what generics are, and what the challenges are in the creation of an approval pathway for generic biologics.
What are biologics? How do they differ from traditional small-molecule therapies?
When you think of a drug, you probably think of a pill like Tylenol or Lipitor. You may not be as familiar with biologics, which are attracting a great deal of attention from policymakers and media. Biologics represent a different set of drugs, distinguished by their size, their informational and manufacturing complexity, and their therapeutic advantages.
If you were to look at most drugs under a microsope, you would find that they are actually rather small relative to a typical biologic. Acetaminophen, which is the active ingredient in Tylenol, weighs 150 daltons (a dalton is a unit of atomic mass). Enbrel, on the other hand, which is a top-selling biologic indicated for several autoimmune diseases, weighs 150,000 daltons. To put that thousand-fold difference in visual terms, if Tylenol weighed as much as your mountain bike, then Enbrel would weigh as much as an unfueled 12-passenger private jet. Hence you will often hear people in the pharmaceutical industry refer to “small molecule” drugs and “large molecule” drugs — because these are two truly distinct classes.
Biologics are often designed to closely mimic the body’s own specific natural processes. Because of this higher specificity, biologics tend to bind to drug targets in the body more precisely than do traditional drugs, which may bind to other unintended targets in the body, placing the patient at greater risk of side effects.
On top of it all, there is currently no defined pathway at the FDA for companies to develop generic versions of biologics, so biologic manufacturers retain data exclusivity over their products. Not surprisingly, the therapeutic and market advantages of biologics have caused pharmaceutical companies to focus their efforts on developing or acquiring biologics over small-molecule drugs. In fact, according to a recent forecast, by 2014, seven of the top ten drugs in America will be biologics, including every single one of the top six.
Unfortunately, while biologic therapies provide a great deal of therapeutic benefits, they are also extremely challenging for biopharmaceutical companies to develop and manufacture, because they are composed of entire proteins, carefully grown through recombinant DNA methods which are newer and less practiced than traditional drug chemistry methodologies. A traditional drug is usually derived through a set of chemical reactions. It’s a lot like following a recipe. Synthesizing a biologic, however, is a bit more like cloning a cat. In order to synthesize a biologic, host mammalian cells, usually Chinese hamster ovary cells, must be implanted with a gene that codes for the desired drug. The host cells are maintained in a special bioreactor that is designed to keep the cells alive as they translate, synthesize and excrete the drug. The broth of cells must then be harvested from the cells, modified, purified, and tested. The solution is finally packaged into vials or pre-filled syringes for distribution.
This manufacturing process is unusually challenging to reproduce consistently, even within a company. For example, Johnson & Johnson manufactures epoetin alfa, an anemia therapy, under the name EPREX in Europe. In the late 1990s, J&J changed its manufacturing process for EPREX at the request of the EMEA (the European version of the FDA). The process change caused some patients to develop pure red blood cell aplasia, a serious adverse reaction. Rather than receiving the benefit of the anemia therapy, these patients actually lost their ability to make red blood cells because they produced an antibody (triggered by the faulty EPREX) that inactivated both the EPREX and the body’s natural protein that is essential for red blood cell production. J&J eventually determined the cause of the adverse reaction and corrected it, but only after a lengthy and expensive investigation.
Because of the intense development and manufacturing process, biologics are also significantly more expensive than traditional therapies. Herceptin, an effective treatment for some forms of breast cancer, can cost as much as $48,000 for one year’s worth of treatment. It’s important to keep in mind, however, that virtually every drug company provides programs to help underinsured or uninsured patients get financial assistance in the form of co-pay cards, co-pay grants, or free drug programs. Simply contact the drug manufacturer.
Why have biologics gotten so much attention from healthcare reformers such as Rep. Waxman and President Obama?
The high cost of biologic therapies has attracted attention from both private payers, such as Aetna and UnitedHealthcare, and public payers, such as Medicare, Medicaid, and state health insurance programs. While payers agree that the therapeutic benefits of these treatments are important, they are still anxious to limit their exposure to the high price tags. Most insurers require several other therapeutic steps before allowing a physician to prescribe a biologic therapy.
Wait, what exactly is a generic? And what’s all this talk of bioequivalence?
The Hatch-Waxman Act of 1984 established a pathway for generic versions of small-molecule drugs to be offered to the public. Once the patent ends on a drug, generic drug makers may manufacture and sell the same drug without repeating the research, expensive clinical trials, or marketing efforts conducted by the original patent holder. These savings allow generic manufacturers to sell their versions for a lot less.
In order to gain approval, the maker of the generic must still show bioequivalence to the original drug, called the “reference listed drug” in the generic drug maker’s application. In a bioequivalence study, the reference listed drug is administered to one group of healthy volunteers, and the generic is administered to a second group. The blood concentrations of the active ingredients are measured over time and graphed. If the generic drug’s graph lies between 80% and 125% of the graph of the reference listed drug, then the two are deemed bioequivalent, and the generic drug is approved. Once approved for the market, it may be sold and independently substituted by a pharmacist for the branded medication without telling the physician, assuming the doctor has not expressly forbidden generic substitution. This last permission is referred to as the “interchangeability” of the drug.
Why can’t Congress just duplicate the same approval process used for generic small-molecule drugs?
In theory, Congress could. In practice, however, there are several technical hurdles that remain to be cleared. As discussed above, the processes used to create biologic therapies are extremely sensitive to manufacturing changes, as in the EPREX case. If a generic biologic manufacturer develops its own process, there is a good chance that the quality of the product would differ from that of the reference listed drug. Furthermore, no one has yet confidently measured bioequivalence for a biologic.
Frank Torti, Chief Scientist of the FDA, summarized these issues very well in a September 2008 response to a Congressional inquiry about follow-on biologics:
Because of the variability and complexity of protein molecules, current limitations of analytical methods, and the difficulties in manufacturing a consistent product, it is unlikely that, for most proteins, a manufacturer of a follow-on protein product could demonstrate that its product is identical to an already approved product. Technology is not yet sufficiently advanced to allow this type of comparison for more complex protein products.
All is not lost, though. The FDA could still create a pathway for generic biologic manufacturers to develop “biosimilars,” which are products that are intended to be close to a reference listed drug but cannot be shown to be the same. Because they are not the same, biosimilar manufacturers would likely have to conduct clinical trials to show that their version is safe and effective for human use, and can be manufactured consistently.
What are the realistic cost savings?
Because of the added cost of clinical development, testing, and marketing of a biosimilar product on top of the difficult manufacturing process, and competition, generic biologic pricing is more likely to resemble brand-to-brand biologic competition than the generic-to-brand competition seen in the small-molecule drug marketplace. Therefore, it’s not yet clear how much more affordable a FOB would be for health insurers. Without being able to show that the products are truly identical and therefore interchangeable, physicians are also likely to be reluctant to try what is essentially a “new” drug that does not truly share the established track record of the original drug. Payers and patients may be excited about the lower cost but skeptical of potential safety issues. As a result of these factors, generic biologic manufacturers may ultimately fail to capture enough business to make up for the upfront expenses of clinical testing, as well as the ongoing manufacturing and marketing expenses.
The Federal Trade Commission recently published a report that studied and called out these limitations. The consequences of the market dynamics imply that only two or three companies with large biologics manufacturing capabilities will even bother to get involved in this field, because only those companies will already have the plants and people to compete effectively. Ironically, the FOB manufacturer for a given reference drug will probably be other biologics innovators who already have the manufacturing capabilities but don’t normally compete in that particular market.
What would be some of the other implementation challenges for the government?
For one, CMS would need to decide how to bill and code for the new products, a subtle referendum on how identical the biosimilars will really be. If they give the generic versions the same codes as the originals, interchangeability is easier and the cost savings are more likely to materialize. On the other hand, it’s important for both the FDA and CMS to track adverse events with these new products (an activity known as “pharmacovigilance”), which is easier to do if the codes are different.
Where does the policy debate stand? What are the Eshoo and Waxman proposals?
The current Waxman bill is remarkably similar to the Hatch-Waxman Act of 1984, which was originally designed for small-molecule drugs. It would not require any new clinical trials for generic biologics provided that the generic had a “highly similar molecular structures,” and allows a case-by-case determination on whether or not safety and efficacy data would be required before pharmacies could substitute generics for reference biologics without telling the physician, but the default would be to allow substitution on approval. The Waxman bill allows for five to nine years of data exclusivity for the original patent holder.
The current Eshoo bill would require clinical trials comparing the generic biologic to the reference biologic, unless the FDA waived them. Rather than automatically granting interchangeability upon approval, the FDA would have to publish guidance with data that describe the criteria required for interchangeability. The bill also recognizes the greater challenge in developing biologics by allowing for twelve to fourteen years of data exclusivity.
Can the healthcare system really save billions of dollars with biosimilars?
President Obama’s speech to the AMA suggested that billions of dollars would be saved by the creation of a biosimilars approval pathway. Several others to study the issue have cited fairly conservative numbers. Avalere Health put the federal savings at $3.6 billion over a ten-year period, while the Congressional Budget Office says $6.6 billion. Avalere’s model assumes moderate discounting, several entrants, slow uptake of biosimilars, and a ten-year data exclusivity period. The CBO report scores a bill that resembles the Eshoo option described above, but doesn’t account for some of the market dynamics discussed above and in the FTC report.
Finally, to keep pharmaceutical costs in perspective, policymakers should remember that prescription drugs currently make up only 10% of healthcare costs, while physician services make up 21% and hospital care makes up 31%. The CBO estimate also predicts that follow-on biologics would save $25 billion on national biologics expenditures over ten years. Even if correct, those savings still make up one-half of one percent of all national spending on prescription drugs, which is itself one-tenth of all healthcare spending in the United States.
Which option makes more sense?
Overall, the Eshoo bill appears to do the best job of reflecting the current technical challenges particular to biologic therapies. The need for clinical trials to insure the safety, efficacy and quality of FOBs ought to be non-negotiable. However, given the high cost of becoming a FOB manufacturer, and the small number of likely entrants, the optimal length of data exclusivity is a good open question. Henry Grabowski of Duke University studied the issue and concluded that an ideal breakeven point is 12.9 and 16.2 years, also suggesting that the Eshoo option is the most likely to drive economic growth. The European Union currently allows for biosimilars and permits ten to eleven years of data exclusivity. Let’s hope that policymakers work hard to thoughtfully strike the right balance that maintains both a stream of innovative therapies from scientific pioneers and a structure that wisely manages costs for payors.
Author’s bio:
Jonathan Sheffi is a summer intern in the FDA Office of Biotechnology Products. Before the FDA, Jonathan worked for Amgen, first as a marketing analyst and then as a biopharmaceutical sales rep. He will start at Harvard Business School in the fall of 2009, and is seeking an internship opportunity for the summer of 2010. Follow Jonathan’s blog at http://jonathansheffi.com/ and on Twitter at @sheffi.
Acknowledgments:
Thank you to Val Jones (Better Health), Niko Karvounis (The Century Foundation), and Kimberly Barr (UnitedHealthcare) for their comments and suggestions.
Disclosures:
All included information has been derived only from publicly available sources. This blog post reflects the author’s personal opinions and do not represent the opinion of any other organization or individual.
June 29th, 2009 by EvanFalchukJD in Better Health Network, Health Policy
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Everything is McAllen, Texas.
It’s all part of our “uniquely American” approach to many issues: oversimplify the problem, so we can solve it. Ideally, on an artificially short time line.
In the case of health care reform, let’s say we get ‘er done by August 1.
When we talk about health care reform, we are really talking about dozens of different issues. Is health care reform about covering the uninsured, or about cutting costs for employers? Is it about having a publicly-funded health plan, or changing reimbursements to doctors? Is it about longer life expectancies or creating insurance cooperatives? Is it about caps on medical malpractice awards, or comparative effectiveness? Is it about healthier lifestyles, or cutting the cost of prescription drugs? Is it about cutting administrative waste, or incentives for more people to go to medical school? Is it about implementing new health care IT, or preventing insurers from making excessive profits?
It’s about all of these things, and more. And that’s the problem, if you’re an ambitious reformer. There is no simple way to get all of these things under one roof.
Well, until Atul Gawande introduced us to McAllen.
The President quickly made Dr. Gawande’s article on McAllen required reading at the White House, telling Senators this is the problem we are trying to solve. His point man on health care, Peter Orszag, has been blogging about it repeatedly. Members of Congress and the press have taken to talking about McAllen as the center of the health care debate. Even doctors from McAllen are calling on the President to come and see for himself.
Others are using it, too. Paul Krugman, in his blog, took on Harvard economist Greg Mankiw for saying that some comparisons of the US and foreign health care systems may be flawed as a premise for U.S. reform. In response Krugman said “read Atul Gawande!” I saw this, too, when I questioned Steven Pearlstein about why he had such a problem with doctors. His only response was “Maybe you should talk to Atul.”
The problems of McAllen make easy talking points. But they are also a convenient way of avoiding dealing with the enormous complexity of the health care system. There are nearly 650,000 doctors in America, millions of patients, thousands of hospitals, tens of thousands of insurance and pharmaceutical companies, hundreds of thousands of employers who provide health benefits, and thousands of other charities, academics, consultants, government agencies and others who have strongly held views about our system. Too often, their voices are not being heard in all the loud talking about McAllen.
And so, if reforming our health care system is, as the President says, a “moral imperative,” why can’t we have a process that treats reform that way? Why the rush to pass reforms that have to be sold under the premise of solving the problems of McAllen?
The President and the Congress are perfectly capable of putting together a respected commission of experts to study health care, in depth, and then return with serious, comprehensive recommendations that Congress and the President can work to enact. Polls show great public support for the idea of reform, but mixed understanding on what reform means. As we see from the evaporating support for reform in Congress, this gap is a serious problem.
We need effective health care reform in America. McAllen isn’t enough to close the deal.
*This blog post was originally published at See First Blog*
June 28th, 2009 by Bongi in Better Health Network, True Stories
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In the old days sometimes confrontation was the only way to get things done. But sometimes anger lead one into useless and unnecessary confrontation. I recently spent some time with my old friend, swimmer’s chest and a story came to mind when that swimmer’s chest saved me from my own anger.
We were on call together. Quite early in the day the chemotherapist called me. He had apparently put a patient on the emergency list the previous day for a portacath and the case didn’t get done. This was due to the fact that the emergency list first did critical cases like actively bleeding patients before they did relatively stable patients. Something like a portacath would tend to get shifted down the list and may even stand over to the next day. This is what had happened here. He now wanted me to do the case.
“Sure I’ll do it” I said. “As long as it’s on the list as soon as it comes up I’ll be there.”
“I want it done now!” he retorted. I was not impressed.
“Well phone the anaesthetist on call and motivate for him to move it up the list.” I said helpfully.
“That is not my job! You will do that!”
It was clear we had a communication problem. Whenever I had a telephonic communication problem I would put down the phone and take the effort to go to the relevant person to sort it out face to face. Not only does it help to speak things out in person but the walk usually gave me time to calm down (there was more than enough residual anger in those old days to go around). This is what I did here. I turned to swimmer’s chest and told him to accompany me. Off we set at speed.
We walked into the chemotherapy ward and asked to see the relevant doctor. Soon he was there in front of me. swimmer’s chest hung back. I introduced myself and explained that I was more than willing to do the surgery but I had no control over the order of the list. That was entirely in the hands of the anaesthetists. If he felt the case needed to be done before the other cases on the emergency list then he should phone the anaesthetist and discuss it with him.
“You will phone the anaesthetist yourself and you will do this case right now!” he said.
I could feel my anger slowly turning into fury.
“No! you will!” as I said it I clenched my fists and took a step towards him. Swimmer’s chest realised things were on the verge of going south. He later told me he thought I was going to punch the guy. I denied this, but the thought was going through my mind at the time, I confess.
So my good friend stepped in front of me with his broad chest and nudged me backwards. He then started speaking to the chemo doc in a calm diplomatic voice. He also subtly and slowly (almost so one didn’t notice) ushered the guy further and further away from me. By the end of it we left with the chemo guy feeling that we were there for him and would do all we could. I don’t think he even had an idea of how enraged he had made me.
Walking away swimmer’s chest asked me if I was mad. I had only a few month’s of training left and something stupid like getting into a fight was just about all that could stand in the way of me becoming a surgeon.
Those times in the end brought out the worst in me. By the end of my studies I knew I needed to get away from it all. I had very nearly become something I did not like. After leaving pretoria I gradually rediscovered the true me again. It was still there to my relief.
*This blog post was originally published at other things amanzi*
June 28th, 2009 by Emergiblog in Better Health Network, Health Policy
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Well, apparently they call a nurse!
Either that or Nurse Nellie caused the headache.
But we know that nurses never cause doctors to have headaches, so that can’t be what’s happening.
Ha!
Trust me, there have been a few doctors over the years that have given me major headaches and I have no doubt that I have been the impetus behind a few MD migraines myself!
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The guy in the Anacin ad must be doing what I’ve been doing for the last two days.
Trying to get a grip on healthcare reform.
That alone is enough to give you a migraine.
There is so much information and conjecture and opinion and debate, it is difficult to know where to start.
Who gets covered? What gets covered? Who pays? Who decides the charges? Who decides the fees? Who has an agenda: political, financial or otherwise? Private or public plan?
And the most important question of all: Who is fighting for what is best for the patient?
Because, when all is said and done, WE are “the patient”.
*****
Okay, so I’ve come up with some foundations; these are things that I feel must be at the heart of any health care reform debate:
1. Every citizen must have health care coverage.
2. Every citizen needs to own their health care coverage.
3. There should be a choice between private and public plans.
4. Every citizen must be able to choose between a private or a public plan and switch between as necessary.
5. Each plan must cover basic health care: physicals, screening, immunizations, well care.
6. Each plan must cover chronic or catastrophic illnesses. (Diabetes, asthma, MS, cancer – just a few examples)
7. After basic health care and chronic/catastrophic illness, each citizen should be able to choose how they want to be covered. I have heard this called the “cafeteria plan”.
*****
Gee, I don’t ask for much, do I?
We don’t have to invent the wheel here. Other countries have gone before us; there are models of universal coverage we can study.
The operative word here is “study”. Take what is good, understand what does not work and use that knowledge to form a unique form of universal health care that meets the needs of the citizens of the United States.
*****
Probably the easiest way to tackle health care is from a personal angle.
I just found out what my COBRA payment would be if I left my job tomorrow.
I’m hoping my jaw heals before I go to work on Thursday.
But that’s a topic for the next post.
*This blog post was originally published at Emergiblog*
