Lessons from the 4th Century BC

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Transcript Lessons from the 4th Century BC

Lessons from the 4th Century BC:
“First Do No Harm”
Wendy J. Wolf, MD, MPH
President & CEO
Maine Health Access Foundation
The Maine Health Access Foundation (MeHAF)
Maine’s largest private non-profit health care foundation
created in April 2000 from the sale of Blue Cross & Blue
Shield to Anthem
Charged with increasing access to care state-wide for
Maine’s uninsured and underserved
Current Assets: $110 million
Annual grants & program spending: $ 5 million
The MeHAF mission is to promote affordable
and timely access to comprehensive quality
health care, and improve the health of every
Maine resident.
MeHAF supports strategic solutions for Maine’s health
care needs through grants and other programs,
particularly for projects that serve the uninsured and
medically underserved.
MeHAF has awarded millions to advance its mission
and serve Maine people
Since 2002, MeHAF has awarded over $30 million in cumulative
grant and program support to nonprofits across Maine
MeHAF’s role in advancing access to medications for
people who are uninsured, and promoting better
patient and family-centered care
Grant Programs:
 Medication Assistance Programs: Pharmacy
benefit enrollment & medication management
 Integration Initiative: Grants to advance
integrated care between primary care, mental
& behavioral health, and oral health
Special Grants: Medicare D outreach &
enrollment with GOHPF, DHHS, Legal Services
for the Elderly and Area Agencies on Aging
Advocacy: ME Citizen Leadership Fund grant for
Rx drug education for Maine’s seniors and people
with disabilities
Convening: Medication Management stakeholder
group meetings
Policy studies: Adverse drug event analysis
Education support: Academic detailing meeting
and this conference
Prescription Drugs:
The good news
The development of effective pharmaceuticals has
revolutionized medical care, offering treatments for a
vast array of acute and chronic illnesses:
Some pharmaceuticals prevent or cure illnesses,
especially those that historically resulted in
premature death and disability (antibiotics, vaccines)
Most pharmaceuticals focus on alleviating the
symptoms or side effects of chronic disease
The US has been a leader in the development of new
pharmaceuticals and the industry is one of the nation’s
most successful private sectors in the US economy.
Prescription Drugs:
The not-so-good news
The growth of prescription drugs has resulted in an
explosion of polypharmacy that often causes negative
health outcomes
The rise of prescription drug costs is a significant factor
in the rise of overall health care costs in Maine and the
USA, and the retail prices of Rx drugs have more than
doubled over the past decade
The growth of pharmaceutical industry profits has driven
a greater focus on “copy-cat” drugs that target
“profitable” illnesses.
Direct to consumer advertising has fueled consumer
demand for drug therapy for many conditions that can be
improved by life-style modification
Prescription Drugs:
The concerning news
The growing use of pharmaceuticals in humans and
animals has driven new issues for concern:
Growth of pro-industry bias that has eroded the
objectivity of scientists, physicians and regulators
Promotion of off-label use to expand market share
Rx overuse and resistance
“Medicalization” of non-illness
Unintended consequences of newer technologies
(genetic engineering)
Cross-species effects
Environmental impact
Prescription Drugs:
The not-so-good news
Growth of Rx drug use
Dangers of polypharmacy
The role of medications in
rising health care costs
Growth of Rx Drugs
Prescription drug use is the highest ever among insured Americans*
More than half of al insured Americans (51%) are taking Rx
meds regularly for chronic health problems
Americans buy much more medicine per person than another
Most widely used drugs:
Among seniors, 28% of women
and 22% of men take > 5 meds
Largest increase in 20–44 year olds
primarily due to more drugs for
depression, diabetes, asthma
ADD, seizures
*Data from Medco Health Solutions Inc, May 2008
Rise of Polypharmacy
Average # of prescriptions filled by
each person in the US increased from
8.9 per year in 1997 to 12.6 per year in
Polypharmacy increases the risk of
drug-drug interactions and adverse
drug events (ADEs)
ADEs account for a significant number
of hospitalizations in Maine (based on
primary or secondary discharge
Quality medication management needs
to focus on managing ALL medications
– and DISCONTINUING medications
that are ineffective or no longer needed
Prescription drugs account for a significant proportion
of National Health Expenditures
National Expenditures (billions)
Levit et al. Health Affairs, Jan/Feb 2003 and 2005 CMS Services Data
Projected increases in national health expenditures for
prescription drugs (in billions)
DHHS/CMS projections
Why are prescription drugs so costly?
Drug research & development is costly
PhRMA estimates the average cost of bringing one new drug to the
market is $500 million
The industry estimates this process takes an average of 12-15 years
However, the largest portion of the pharmaceutical industry’s
budget goes toward advertising and marketing rather than
research and development
Pharmaceutical companies spend 2 ½ times more on
marketing and administration than on research and
Academic researchers in public and private
institutions frequently spearhead the development of
new drugs with funding from the federal National
Institutes of Health. Although tax dollars support this
research, these discoveries are increasingly sold to
private industry for development and profit.
Direct to consumer advertising is a significant factor driving up the cost
of Rx drugs – but does it result in better quality and health outcomes?
The drug industry spends $3 billion/year in DTC ads
The industry argues:
Educates patients about medical conditions, treatment options, side effects, etc
Prompts dialogue between providers and patients
Improves appropriateness of prescribing
Improves compliance
Others say:
Increases cost by prompting requests
for brand name drugs
Promotes newer more expensive Rx,
often with higher profit margin
Prescription Drugs:
Opportunities for advocacy
The growing use of pharmaceuticals in humans and
animals has prompted new issues for advocacy:
Growth of pro-industry bias that has eroded the
objectivity and trust by scientists, physicians and
Promotion of off label use to expand market share
“Medicalization” of non-illness
Rx overuse and resistance
Unintended consequences of newer technologies
(genetic engineering)
Cross-species effects
Environmental impact
Prescription Drugs: Pro-Industry Bias
Erosion of Firewalls between Science and Industry
The pharmaceutical industry has transformed the culture of medical school and
scientists conducting basic research, instilling a pro-industry bias*
Example: Dr. Charles Nemeroff of Emory University—the principal
investigator on a government-financed study of antidepressant drugs made
by GlaxoSmithKline—failed to report almost a half a million dollars he was
paid in fees and expenses from the drug company while he led the study
(NY Times, 10/11/2008)
Researchers were 5 times more likely to
recommend a drug when a study was funded by the
industry rather than by a non-profit
Drug companies pay for postgraduate accreditation
courses for doctors. Under the guise of offering
educational opportunities for doctors, drug
companies use the lectures and conferences they
sponsor to push their products
Schools and medical centers often hold equity in
the start-up companies that sponsor their research
*Angell, JAMA Sept 2008
Prescription Drugs:
Opportunities for advocacy
Special issues for children
Promotion of off label use
Applying adult models to
childhood conditions
“Medicalization” of non-illness
Rx overuse and resistance
Unintended consequences
Prescription Drugs: Opportunities for advocacy
Insure access – and advocate for standardization of pharmacy benefit programs
Promote quality medication management that insure that unneeded or ineffective
medications are eliminated (and returned to drug disposal sites).
Advocate for comprehensive health information through better health IT and
Support policies that insure scientific rigor, strict attention to conflict of interest and
insure firewalls between industry, scientists, and providers to insure science and
evidence is unbiased (Ex: Grassley/Kohl bill that would require drug companies to
publicly disclose payments to physicians > $500/yr)
Broad program to support academic detailing to combat promotion of brand name
drugs and off label use
Advance public policies that balance medication costs with quality and effectiveness
Consider regulation to limit “medicalization” of non-illness so insurers are protected
from mandates to cover non-evidence based treatments
Proactive hospital and insurer policies, and consumer education to prevent Rx overuse
and resistance
Surveillance/examination of unintended consequences of
newer technologies (genetic engineering)
Convening of key leaders/researchers to examine
cross-species effects
Policies and public education to mitigate environmental impact
These issues touch every person in Maine –
and we all have a stake in addressing these
health care challenges