Author: Ann Marie Marciarille

In her beautifully written review of Stephanie Land's new book Maid: Hard Work, Low Pay and a Mother's Will to Survive, Emily Cook notes  in the NYT that:

 

For a while, as Land recounts in "Maid," her memoir of her time as a cleaner, she was on seven kinds of government assistance, and still hardly surviving.  The paperwork she was forced to complete in order to qualify for help was interminable: applications with questions about her plans for the years to come, detailed proof of income that included documentation of her schedule and letters from clients verifying that she did indeed work for them, and continual updates to account for any change in status.

 

Yes, we have always been determined to make the poor prove their worthiness, at least in part by demonstrating the perseverance to obtain any help at all. It was the ACA, by promoting simplification of Medicaid application and maintenance of Medicaid eligibility status that really shook that up. Or, tried to.  The ACA, however, did leave the states to experiment in how best to streamline these processes.

We can learn something about the different directions taken by the various states by considering a late 2018 report from  MACPAC, surveying how and how well Medicaid eligibility processing was streamlined in representative states.  It makes for some pretty interesting reading.  

The big takeaways? Integrated applications are the goal.  Medicaid applications sometimes do not mesh well or at all, however, with applicants for other forms of benefits. And so the gains were significant, but only incremental.  The biggest problem?  Completely different standards of eligibility between and among the programs. 

Torrent Pharmaceuticals' expanded recall of some lots of losartan potassium has generated a blizzard of correspondence for people using losartan — first one letter from the dispensing pharmacy, then another as the recall expanded, and even communication from insurers.   Each letter urges the recipient to check the NDC and Lot numbers of already prescribed losartan for possible recalled product.  One of these letters is several pages long and none are particularly brief.

Is it realistic to expect an American consumer using losartan to take responsibility for keeping track of all the recalled and expanded recalled lots?  Shouldn't the manufacturer, relevant PBM, and dispensing pharmacy be able to identify the group of consumers sold these lots? Or, is this like the Takeda airbag recall, so expansive that eventually (over a period of a few years), it seemed like most cars in America were in recall?

The FDA, it turns out, leaves it to individual pharmacies or pharmacy chains to — in great part — determine how they will get the recall information out to their customers once they have received word from the FDA.  Perusing the websites of both Walgreens and CVS, it seems they both rely on a general written notice advising the patient to garner the label information necessary to determine if they are targeted.

The problem with this is that none of these letters offer what I think would be most useful: a mark up of a CVS or Walgreens prescription drug dispensing label with markers for where to find the the NDC number and the lot number.

Why make this so hard? After all, who has the best information on which product, NDC, and lot numbers were dispensed to whom?

 

 

 

Thank you, Judge Posner and all the other retired judges who signed on to the amicus brief filed in the class action concerning access to the courts, Pacer fees, and how significant Pacer fees collected may be spent. Although the summary judgment motions in the case focus on how far from actual cost the Pacer fees may be set and how far from court access the fees may be spent, the Posner et al amicus argues that no Pacer fees should be allowed, making this an amicus brief that supports neither side. 

Although it is unfashionable to admit it, of course Pacer fees of all kinds serve to restrict and sometimes deny meaningful access to the courts by people of modest means.

Danielle Ofri's article on "The Insulin Wars" is good as far as it goes but stops short of great for a few reasons: failure to address insulin consumption pattern changes from human insulins to higher priced human analog insulins and failure to place this insulin war in place as part of  what may be seen as a larger war on diabetics. Yes, I am not discussing a war on diabetes. Sadly,  I am discussing a war on diabetics.

Insulin utilization has trended toward the higher-priced human analog insulins, although even the price of human insulins has increased. Still, as a 2018  ADA white paper stated, “human insulins are available at the pharmacy for $25 to $100 per vial compared with human insulin analogs at $174 to $300 per vial.” And, for historic reasons, human insulins are available over the counter in the United States. If you've anticipated where I am going on this, you are wondering why every effort is not being made to move every insulin -dependent diabetic who can tolerate it to OTC human insulin and to side step insurance company-pharmacy benefit manager game playing, by purchasing it OTC.

I see a health care system that not only allows but actually incentivizes the crazy kind of drug hopping and formulary tweaking that leaves diabetics uncertain as to which kind of insulin at what price will be available to them should remind you that we live in a culture where common roadside signs offer to purchase diabetes testing supplies for the same reason.  The very supplies necessary to determine when and if insulin is necessary and to attain good control are unaffordable to many.

Does Danielle Offri even look up to see the "we buy diabetes testing supplies" signs plastered at every intersection when driving to and from Bellevue Hospital?

Kratom, an herb, has gained in popularity as opioids have declined in popularity.  The New York Times asks :"Is Kratom Nature's Answer to Opioids?" but there is an equally important question folded within that one: Is Kratom sufficiently opioid-like (from the coffee plant family but binds to certain parts of the brain much like opioids) to be scheduled like the most dangerous of drugs with no medicinal value?

Several states feel they have heard enough on this debate and banned Kratom outright.  The FDA attempted an emergency Schedule One designation but, pushed back to the ordinary scheduling procedure, continues to consider the issue.  HHS has asked the FDA to add Kratom to Schedule 1, so a fair amount is at stake.

What is so interesting to this particular scheduling debate is the argument over whether Kratom is the kind of drug that will help opioid addicts move away from opioids or whether Kratom is the kind of drug that will eventually lead its addicts to opioid addiction — either through abuse of Kratom itself; encouraging the move on to classic opioids; or increasing harm  by the use of  Kratom as part of a drug cocktail including opioids.

So, is Kratom a good herb or a bad herb?  And, how would we know, when so little has been done to study its use in treating depression and chronic pain? 

An executive order consolidating prescription drug acquisition pricing in California has already been signed and taken effect.  As Governor Newsom took to social media to explain, this means Medi-Cal (roughly 2 million Californians alone), CALPRS, Dept. of Veterans affairs and Dept. of Corrections and Rehabilitation will now bargain collectively for prescription drug acquisition price contracts covering roughly 13 million covered lives.  This contemplates a long overdue expansion of Medi-Cal's mighty purchasing power to other non-Medi-Cal entities that have had to acquire certain prescription drugs at prices that reportedly  far exceed Medi-Cal's acquisition cost. I have blogged about this before.

Such a change would likely markedly impact the Department of Corrections most immediately, where  California's sentencing practices have created a demographic where a significant percentage of the prison population is of advanced age as well as medically complex. The Department of Corrections has been candid about its disappointment in being denied Medi-Cal acquisition rates for prescription drugs.

Just what is the spread between Department of Corrections and Medi-Cal's prescription drug acquisition cost?  Ah, that is — in part — proprietary information.  The pharmaceutical manufacturers do not want the left hand to know what the right hand is doing, lest other government agencies demand to be in on the deal and lest private purchasers also demand Medi-Cal acquisition cost pricing.

You see, California's lower prescription drug discounts could be from the undisclosed cross-subsidization of others, precisely those others who now seek to access the Medi-Cal acquisition cost. 

So, who's left to the be cross-subsidizer?  Buyers in other states? As Governor Newsom notes in his video, California's actions here may well create incentives for other states to follow suit.  This could get interesting.

 

 

I am not sure why cardiologist Haider Warrich is surprised that the most compelling argument in favor of taking statins, for a particular unsophisticated patient, was the revelation that he had made the same recommendation to his father in a similar medical situation.  After all, isn't one of the best questions for those with limited medical research skills and limited time in which to ask questions the one that asks the provider what they would recommend were their mother the patient? Appears to cut right to the chase, doesn't it?

Of course, there is a lively dispute about whether doctors who treat every patient like their mother actually are more likely to harm their patients. So, there may well be  dangers in saying "treat me as you would your mother" but are those dangers as great as relying on what Warrich calls "Google medicine?" 

If there are good evidence-based reasons why we urge health providers not to provide care to close relatives, maybe none of us should want to be treated as any provider's mother would be. And maybe Dr. Warrich's solution is no solution at all. 

 

 

I recently watched a movie with precious few laughs. 

There were a few good moments in The Late Bloomer, however, the best of which was when our sex therapist who has never passed through puberty suffers a head injury and ends up in the ED of a local hospital.  The consulting neurologist breezes in as our protagonist regains consciousness and orders a MRI of his brain. One beat later the neurologist turns to the patient and asks: "What kind of insurance do you have?"  When our protagonist responds with the information that he himself is a physician, the doctor says: "In that case, let's have an MRI and a CAT scan."

Bad movie, one great satirical moment. I'm laughing again as I read where one of the scriptwriters talks about how the original script response to the question about health insurance was supposed to elicit a cry of "Yahtzee!" from the ED physician.

Judge Joseph L. Touro has died.  The Boston Globe notice tells us how his long involvement with the Belchertown State School began in 1973.  He was a fair and honest judge.  And he simply did not think that the citizens living at the Belchertown State School deserved to live in sub-human circumstances simply because they were children with intellectual disabilities.

I first visited the Belchertown State School in 1978, as part of a volunteer program for helping with the socialization of individuals hoping to move to less restrictive settings, courtesy of Judge Touro's strong stance on the quality of their lives.  At this point, many of the Belchertown State School residents had moved out of the huge congregate dorms and into smaller group living in what used to be staff housing. Still, over the years, I did volunteer with groups in the huge congregate buildings, sobering stuff for a teenager.

I learned a lot at Belchertown State School, some of it none to flattering about the willingness of the Commonwealth of Massachusetts and its citizenry (including myself), to define these folks with intellectual impairments right out of the human race.  What I experienced and what I saw, has stayed with me.

It was parents that started the protest but Judge Touro who really took them seriously.

If you haven't read Atul Gawande's article on why doctors hate their computers from the New Yorker, you should do so.  It does run a bit long but the first half of the article is definitely worth it (spoiler alert).  Doctors hate their computers for the same reason all of us chained to meticulous time and task reporting requirements do: computers pose both an assist and a distraction to the task at hand. It is easy to like the former and hate the latter without appreciating your own internal inconsistencies.

It is over the half way point in Gawande's article where he briefly mentions what I think is really driving the Taylorism of health care.  Yes, you submit your records, your notes, and your billing outline and then the insurer and others review it to make sure no billing opportunity is missed. I would suggest that improved outcomes and increased standardization are merely the by-products of the true purpose: capturing billable time and services to  be billed at the highest allowable rate.