Pharma cash flows to doctors for consultant work despite scrutiny

This article was published on January 6, 2019 on ctmirror.org, written by Sujata Srinivasan.

ctmirror-toppayments

Image Source: ctmirror.org

With physicians’ compensation from pharmaceutical and medical device companies under increasing scrutiny, payments to doctors in Connecticut for consultant work rose to $8.5 million in 2017, up from $8 million in 2016.

Payments for meals, travel and gifts also increased from $3.2 million in 2016 to $3.5 million in 2017, data from the Centers for Medicare & Medicaid Services show.

Of the total $27.2 million in payments, $4.37 million – or 16 percent – went to 10 doctors holding licenses in Connecticut.

The highest paid doctor was Dr. Paul Sethi, an orthopedic surgeon in Greenwich, who accepted slightly more than $1 million in 2017 in royalty fees, consulting work, and other services from several companies, including Arthrex Inc., and Pacira Pharmaceuticals Inc., maker of Exparel. The drug, Exparel, is marketed as an alternative to opioid painkillers post-surgery. Sethi frequently takes to Twitter to promote the use of a non-opioid alternative and is listed on the Pacira website in a case study. He did not respond to C-HIT’s request for an interview.

Dr. Robert Alpern, dean of the Yale School of Medicine, received $524,611 for his work as a director on the boards of Abbott Laboratories and AbbVie Inc. Alpern said that he does not provide paid lectures, does not speak for the pharmaceutical companies, does not see patients or write prescriptions, and that his work on the boards is “fully disclosed to Yale University and Yale New Haven Hospital.”

“I recuse myself from any decisions related to either of these companies,” Alpern said.

The financial relationships between pharmaceutical and medical device companies and doctors, as well as teaching hospitals, have been disclosed since 2013, under the Affordable Care Act. The law is intended to provide transparency into the business connections between health care providers and the industry.

The law is also driving some doctors—like infectious diseases specialist Dr. Roger Echols of Easton—to give up their license to practice medicine. “It’s why I did not revive mine last year,” he said, referring to 2016.

Echols was paid $526,881 in 2017 for his work as a consultant primarily for Japan-headquartered Shionogi & Co., best known as the maker of the cholesterol drug Crestor. Echols said he stopped seeing patients and prescribing medication years ago, when he transitioned to the pharmaceutical industry.

Even practicing doctors, Echols said, are now declining payment when they meet with him to discuss drug research. “They’ve gone so far that they won’t even allow us to provide a bagel or a cup of coffee at a meeting because that has to be reported.”

Overall, non-research payments to Connecticut doctors fell 8 percent from $29.7 million in 2016 to $27.2 million in 2017, the data show. Much of the decline occurred in royalty and license fees on sales of drugs and medical devices, charitable contributions, and ownership or investments in companies.

In research payments to Connecticut doctors, pharma and medical device companies paid $901,196 in 2017, down from $1.1 million in 2016, according to the data.

Nationally in 2017, doctors were paid $2.82 billion by 1,525 pharma and medical devices companies. Research payments totaled $4.66 billion.

Dual role of doctors

The dual role of doctors as providers of health care to patients and marketers for drug and medical device companies has been scrutinized for several years and has been the subject of extensive research.

One report, published in a medical cancer journal that examined several studies concluded, “All the money and attention drug representatives shower on doctors has its intended effect: building relationships with doctors and ultimately changing how they prescribe.”

A study published in October 2017 by the U.S. Library of Medicine, National Institutes of Health; found that gifts from pharmaceutical companies result in higher drug costs: “More prescriptions per patient, more costly prescriptions, and a higher proportion of branded prescriptions.”

“There is strong evidence that pharma payments are associated with higher prescribing of the promoted medications, and with higher costs,” said Ellen Andrews, executive director of the Connecticut Health Policy Project.

Dr. Bruce E. Strober, a professor of dermatology at UConn Health, said, “Nearly all my colleagues—anybody who is a specialist in the field—do speak for drug companies, and I am compensated for my time, yes. Unequivocally, it does not alter my prescribing habits.”

Strober received $174,279 in 2017 primarily in consulting fees from Eli Lilly and Co., Bristol-Myers Squibb Co., Sanofi Genzyme, Novartis Pharma AG and Amgen Inc., among others. In 2016, the latest year on record, Strober made out 61 prescriptions for Amgen’s Enbrel amounting to $239,996, according to a C-HIT analysis of Medicare Part D data.  The same year, Amgen paid him $17,000.

Many doctors see their role as merely educating their peers, and being compensated for their time and expertise.

Dr. Mark Milner, an ophthalmologist in Hamden, received $186,125 in 2017 primarily in consulting and speaking fees from pharma companies specializing in dry eye, including Allergan Inc., maker of the blockbuster drug Restasis.

“There is nothing unethical if I am paid for my time. I give a comprehensive dry eye lecture whether I’m sponsored by Allergan, or Shire [North] or Bausch [formerly Valeant],” Milner said.

Dr. Steven Thornquist, a Waterbury-based ophthalmologist and former president of the Connecticut State Medical Society (CSMS), said, “The onus is on the individual physician to be ethical. I don’t think patients should give their doctor the third degree.”

It’s a fine line. Dr. Claudia Gruss, CSMS president, said physicians should decline a cash gift. “At the same time, there are certain physician experts that other physicians look up to, and educational events allow a very frank interchange between physicians in the field. We don’t want to decrease productive collaboration.” In 2017, Gruss received $120.94 in the general category – the category includes food and beverage at medical conferences.

Dr. Niranjan Sankaranarayanan, a nephrologist in Bloomfield, does not accept money for consulting and speaking engagements from pharma companies, though he did earlier in his career. “I was naïve. They invited me to talk about a medication that I was already prescribing, but after one or two talks, I didn’t feel comfortable,” he said. “This is a gray zone. They entice you with more and more, and there is no ceiling to this,” Sankaranarayanan said.  He received $201.60 in general category in 2017.

Medical ethicists say the public must know that their physicians very often have complex interests. “Medicare has databases but more research needs to be done on incentives ad kickbacks,” said Dr. Howard Forman, a Yale professor of diagnostic radiology, economics and public health, who often speaks about medical ethics.

“We have to prove cause-causation rather than correlation. It’s pernicious how the money flows,” said Forman.

dg-pharmasense-blog-cta

Troubleshooting Telemedicine

telehealthThe healthcare landscape is changing as providers increasingly offer virtual care options, and naturally it’s taken some getting used to. A recent study by the Deloitte Center for Health Solutions found that while patients who have used virtual care reported a 77% satisfaction rate, only 44% felt that their wait time was reduced compared to an in-person office visit. Some offices are designating doctors for virtual care on specific days of the week to circumvent wait times caused by healthcare professionals bouncing between in-person and virtual patients.

dgb-telemedicine-cta

Why The U.S. Remains The Most Expensive Market For ‘Biologic’ Drugs In The World

women-biologics

This article was published on December 19, 2018 on NPR.org, written by Sarah Jane Tribble. Photo Source: NPR.org.

Europeans have found the secret to making some of the world’s costliest medicines much more affordable, as much as 80 percent cheaper than in the U.S.

Governments in Europe have compelled drugmakers to bend on prices and have thrown open the market for so-called biosimilars, which are cheaper copies of biologic drugs often derived from living organisms.

The brand-name products — ranging from Humira for rheumatoid arthritis to Avastin for cancer — are high-priced drugs that account for 40 percent of U.S. pharmaceutical sales.

European patients can choose from dozens of biosimilars — 50 in all — which have stoked competition and driven prices lower. Europe approved the growth hormone Omnitrope as its first biosimilar in 2006, but the U.S. didn’t follow suit until 2015 with cancer-treatment drug Zarxio.

The U.S. government generally stops short of negotiating prices and drugmakers with brand-name biologics have used a variety of strategies — from special contracting deals to overlapping patents known as “patent thickets”— to block copycat versions of their drugs from entering the U.S. or gaining market share.

As a result, only six biosimilars are available for U.S. consumers.

European countries don’t generally allow price increases after a drug launches and, in some cases, the national health authority requires patients to switch to less expensive biosimilars once the copycat product is proven safe and effective, says Michael Kleinrock, research director for IQVIA Institute for Human Data Science.

If Susie Christoff, a 59-year-old who suffers from debilitating psoriatic arthritis, lived in Italy, the cost of her preferred medicine would be less than quarter of what it is in the U.S., according to data gathered by GlobalData, a research firm.

Christoff tried a series of expensive biologics before discovering a once-a-month injection of Cosentyx, manufactured by Swiss drugmaker Novartis, worked the best.

Without the medicine, Christoff says her fingers can swell to the size of sausages.

“It’s 24/7 constant pain in, like, the ankles and feet,” says Christoff, who lives in Fairfax, Va. “I can’t sleep, [and] I can’t sit still. I cry. I throw pillows. It’s just … awful.”

At first, Christoff’s copay for Cosentyx was just $50 a month. But when a disability led her to switch to a Medicare Advantage plan, her out-of-pocket costs ballooned to nearly $1,300 a month — more than three times her monthly car loan.

Christoff, with the help of her rheumatologist, Dr. Angus Worthing, tried Enbrel, Humira and other drugs before finding Cosentyx, the only drug that provides relief.

Christoff’s case is “heartbreaking,” Worthing says. Continue reading

Getting Creative About Behavioral Health

dgb-behavioral-blog

With behavioral health conditions impacting one in five Americans, it’s no wonder we’re seeing more employers search for ways to provide members with better access to behavioral healthcare benefits.

Statistics show that many employees, including some that are insured, fail to get the mental healthcare they need. Because self-funded health plans provide plan design flexibility, some plans are taking bold steps to address this growing need. While many are using telemedicine to improve access and lower costs, some employers are treating out-of-network behavioral health treatment as in-network, enabling employees to pay the same amount for treatment regardless of which provider they use. Others are covering out-of-network behavioral healthcare services even when their plan doesn’t cover out-of-network services for other types of care.

When you consider that mental illness has become the greatest cause of disability claims in the U.S., it is not surprising that employers are looking for ways to help employees obtain the care they need.

Significant Action is Warranted

There is plenty of research to show that Americans are not getting the mental healthcare they need. According to Mental Health America, despite having health insurance, 56.5% of adults with mental illness received no treatment in the past year.

Another problem is that behavioral health treatments are rarely classified as primary care, and are regarded instead as specialty treatment. This makes people find an in-network provider, go out-of-network, pay higher out-of-pocket costs or avoid treatment altogether. Claims data from Collective Health shows that more than 40% of the 2017 behavioral health spend was out-of-network, which is many times the amount spent on primary or preventative care.

DGB-cfh-cta

Despite Recent Court Ruling – ACA Enforcement Is Still the Law of the Land… For Now

On December 14th, the U.S. District Court for the Fifth Circuit in Texas ruled the Affordable Care Act (ACA) unconstitutional in light of the Tax Cuts and Jobs Act of 2017 which eliminated the tax penalty under the individual mandate. The district court sided with 20 Republican state attorneys general that argued since the individual mandate was eliminated, the entire law was invalidated. The ruling went further and also ruled that all of the consumer protections under the ACA were tied to the individual mandate and they were also unconstitutional. These include the prohibition against insurers charging patients more for pre-existing conditions, allowing children to stay on their parent’s plans until age 26, and removal of caps on coverage.

What’s Next?

The judge in the case did not rule the law has to be enjoined immediately, however, it is unclear when the ruling would take effect. Sixteen Democratic state attorneys general and the District of Columbia filed a motion asking the court to clarify the impact of the ruling and confirm that the ACA “is still the law of the land.” Additionally, a series of appeals will most likely keep the ruling from being enacted anytime in the near future… thus:

  • People can still enroll in ACA health plans in states with extended deadlines (without an extension, exchange enrollment ended on December 14th.);
  • There is no impact on 2019 plans that people may have recently enrolled in. Immediately following the ruling, Seema Verma, Administrator of the Centers for Medicare & Medicaid Services, stated the ruling “has no impact on current coverage or coverage in a 2019 plan;”
  • Employers still face IRS deadlines to file forms 1095-B and 1095-C. (1095-B and 1095-C forms must be delivered to individuals by March 4, 2019. The 1094 and 1095 B & C forms must be filed with the IRS by February 28th if filing paper and April 1st if filing electronically);
  • The Employer Mandate is still in force, penalties have been and will continue to be assessed for failure to file these returns;
  • With the Employer Mandate still in force, Applicable Large Employers (ALEs) should continue to follow the Employer Shared Responsibility Rules (ESR) to avoid a penalty. This means offering a plan that meets minimum value and affordability to at least 95% of your full time employees (defined as those working at least 30 or more hours per week).

The case will most likely make its way to the U.S. Fifth Circuit Court of Appeals and then to the U.S. Supreme Court before any definitive action can be considered.

why-diversified-group

Ben Barnes Unplugged

ben-barnes

This article was published on December 13, 2018 on CT News Junkie, written by Jack Kramer. Photo Source: CT News Junkie.

HARTFORD, CT — Outgoing Office of Policy and Management Secretary Ben Barnes believes two powerful groups — hospitals and municipalities — are the biggest obstacles to Connecticut’s fiscal stability.

Barnes made that statement during a far-ranging discussion Thursday at the Connecticut Voices for Children 18th Annual State Budget Forum.

Barnes joked that he could be so candid because he is resigning his position in a few weeks when Governor-elect Ned Lamont replaces his boss, Dannel P. Malloy.

“It’s the kind of thing you can say when you are two weeks away from the end of service.”

Acute care hospitals, Barnes said, “have used their virtuous status to somehow strengthen their demand for resources that the state cannot afford.”

He said hospitals are a “group that gets what they want virtually all the time.” He said they are the only group he knows of that is able to dedicate all the taxes they pay “right back to their own bottom line.”

He said if the state loses the lawsuit filed against it by most of Connecticut’s hospitals, it will cost the state $4 billion. The lawsuit, which was filed in 2016, challenges the taxing structure the state created for the hospitals. It’s still making its way through the court system and no decisions have been made.

As far as municipalities are concerned, Barnes was just as direct, stating legislators need a change of attitude.

Barnes, who once worked for the Connecticut Conference of Municipalities, the city of Stamford, and the schools in Bridgeport, said he knows that won’t be easy — “I used to work in local government.” But he said until legislators look at the bigger picture of the entire state and not just their own town, Connecticut will have budget problems.

Right now, Barnes said, “no town can ever get less than what they got the year before.”

“We are spending a lot of money on communities that have plenty of money,” he went on.

He cited the Teachers Retirement System as the best example of a system that needs to be fixed.

Currently, the state funds the teacher retirement program. Attempts by the Malloy administration to have the towns pick up some of that cost was met with a huge backlash.

The annual contribution to the Teachers’ Retirement System is about $1.3 billion, but could top $3.25 billion to $6.2 billion by 2032, depending on various experts, because of years of underfunding. Connecticut didn’t start setting aside money to pay for teachers’ retirements until around 1982.

Barnes said the state, sooner or later, has to deal more directly with the fact that more affluent communities such as Greenwich, Weston, and Westport need less state funding than poorer communities such as Hartford, New Haven, and Bridgeport.

“We tried to re-stack the deck to put more resources into neediest communities but it was dead on arrival,” Barnes said. “My parting hope is that majority of legislators will look at this issue again. There is enough money but we are currently spending it on people who don’t need it as much.”

In answer to a question from the audience about the issue of how municipalities could find savings, Barnes said the state needs to get serious about regionalization.

He said the legislature should “compel mergers” perhaps offering incentives to do so. He called that the “kind of big idea” that Connecticut needs to be thinking about, having municipalities with hundreds of thousands instead of a few thousand people with regional police, health, and school districts.

Barnes also talked at length about the issue of state pensions. He said he felt that state workers were unfairly “scapegoated” for the problem.

He said while there are some examples of very high pensions being paid to state employees, the average state pension is about $38,000.

“Local government pensions are way better,” the OPM secretary said. He said those who work in the private sector also retire with much better pensions than the average state worker.

Besides, Barnes said, there is a moral obligation involved.

“The law of the land is that when somebody retires with a pension they have a right to that pension,” Barnes said. “We can’t renege on our deal to employees.”

He said even if there was a legal way found to tear up state pension agreements, “Why on earth would we want to do that? These are folks who are cleaning up after our elderly parents or our grandparents. The idea that we would walk away from that is reprehensible.”

Barnes said while he believes that the budget will be in good hands with Lamont in charge and the newly-elected legislature, he also said he’s worried that the 2019 budget was built with what he termed “one-time sweeps” that will create a $630 million hole that will need to be filled in next year’s budget.

“It’s going to create a huge problem for 2020,” Barnes said.

Barnes did say there was some good news, too.

He said the state has seen a 10 percent increase in the withholding portion of the income tax over the past few months — much higher than has been budgeted.

The state is on track “to see some of the most robust growth” in revenue than it’s seen in the past decade, he said.

Accomplishments over the past eight years that he is particularly proud of include Medicaid and criminal justice reform.

“Crime is down, prison population is down,” Barnes said. He added that the state has also made strides in having greater civil rights and eliminating the death penalty.

Connecticut has also had the best results in the nation when it comes to controlling the per member, per month costs of Medicaid recipients.

“We are a national model,” Barnes said.

He referred to Connecticut as a place “I’m proud to call home.”

Barnes recently landed a new job as chief financial officer for the Connecticut State Colleges and Universities.

why-diversified-group