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Fed up with the rising price of drugs, Ascension Health last month did something unusual. It publicly banned a drug company’s sales reps.
The reason: The company had reclassified three cancer drugs, causing prices to spike.
In a memo to employees, Dr. Roy Guharoy and Michael Gray, two top executives with the Edmundson-based hospital chain, explained: “Already scarce resources will need to be stretched with potential serious impact on the range and breadth of health services we currently provide to our patients and our communities.”
The move proved largely symbolic.
Ascension, the nation’s largest nonprofit health care system, can’t stop buying the needed medications. And the drugmaker, Genentech, defended the reclassifications, saying it was done to ensure the safety of the drugs.
Still, the dust-up did succeed in sending a message to the pharmaceutical industry, says Nick Ragone, Ascension’s chief communications officer: Think twice before raising prices.
“The effect of the ban has been to galvanize other provider systems to speak out against these arbitrary and debilitating price increases,” Ragone said.
The message appears to be getting through.
On Capitol Hill, several congressmen just announced plans to hold hearings on rising drug prices.
Separately, the U.S. Department of Justice is investigating price hikes in generics, and issued subpoenas to two generic drugmakers, according to a report in the Wall Street Journal.
Every provider — from big chains, such as Ascension and Creve Coeur-based SSM Health, to much smaller players, such as St. Anthony’s Medical Center in St. Louis and Ladue Pharmacy — can point to recent drug price increases.
For example, St. Anthony’s says it is paying substantially more for doxycycline hyclate, a generic antibiotic that has been on the market for years, according to Dan Johnson, pharmacy director.
St. Anthony’s didn’t provide pricing specifics. But a statement last week issued by a congressional committee said the price of a bottle of doxycycline hyclate shot up to $1,849 from only $20 in fall 2013.
Over at SSM, the pricing problem continues to grow. “It’s always been a small issue, it just seems like there are more and more items that are heading in this direction, and creating a substantial problem for us,” said Tim Roettger, vice president of pharmacy services for SSM in St. Louis.
A year ago, Ascension paid $2.89 for a 45-gram tube of a generic topical steroid cream, clobetasol propionate. The health system is now paying $198.64 for the same tube.
Those kinds of increases add up. With a network of more than 131 hospitals across the country, Ascension’s spending on drugs has risen by $36 million, or 9 percent, in the last year. Two-thirds of the overall increase — $23.5 million — could be attributed to costlier generics, said Mary Ella Payne, Ascension senior vice president of advocacy.
“We can’t absorb these prices,” Payne said.
Ascension’s size gives it more leverage than most other hospitals, especially independent ones, to bargain with pharmaceutical manufacturers on prices. Still, Ascension’s scale has done little to curb the price hikes, Payne said.This copyrighted story comes from the St. Louis Post-Dispatch, produced in partnership with KHN. All rights reserved.
And just because Ascension is paying more for generics doesn’t mean it will be paid more for their services by insurance companies to reflect the full cost of the drug.
“For inpatient care, hospitals are typically reimbursed on a per-procedure basis, so higher generic drugs costs could not necessarily be passed on to the payer,” said Adam Fein, president of Pembroke Consulting Inc.
What Fein means is that commercial insurance companies and Medicare already have set prices in place for each procedure or visit to a hospital. So even if a hospital were to bill the insurance carrier more to reflect the higher cost of a drug, it doesn’t mean the hospital will get paid what it actually bills the carrier.
An analysis published by Fein, considered an industry expert on the economics of the pharmaceutical industry, shows retail prices for generics have increased and in some cases there were “mega increases.”
But the impact isn’t limited to hospitals.
Rick Williams, owner of the independent Ladue Pharmacy, has been affected by the price hikes as well. Sometimes acquiring a drug costs more than how much he is paid by insurers for selling it to customers.
“Number one: We take care of our customers,” Williams said. “And we’re going to take it on the chin for them sometimes.”
The price increases are getting attention on Capitol Hill, though it’s unclear what policy prescriptions a lame duck Congress can provide.
U.S. Sen. Bernie Sanders, the independent from Vermont, and Rep. Elijah Cummings, D-Md., announced they will hold a hearing this Thursday on “skyrocketing” prices for generics, like digoxin, a medication used to treat congestive heart failure, which went from 11 cents a pill in October 2012 to $1.10 a pill in June.
“These huge price increases are affecting the pocketbooks and health of millions of Americans,” Sanders and Cummings said in a joint statement.
The lawmakers are likely to hear examples of how drug prices are rising; they’re unlikely to get a clear explanation why.
Some industry analysts point to shortages as one of the major causes for price hikes, and those shortages can occur when manufacturers either incur problems making the drug or quit making it altogether. And when there are fewer manufacturers, it can cause a domino effect in the market as other manufacturers are left to pick up the slack to cater to remaining demand. Price hikes result.
But that’s how a free market works, said Ronny Gal, pharmaceutical industry analyst with Sanford C. Bernstein & Co.
“There are shortages, and some generic drug manufacturers are being opportunistic,” Gal said. But that’s not illegal.
As health care costs rise, the drug manufacturers are continually being squeezed to lower prices by everyone from retailers, hospitals to group purchasing organizations. That pressure on margins causes some to leave a certain drug behind, said Scott Griggs, assistant professor of pharmacy administration at St. Louis College of Pharmacy.
“With consolidation they are trying to become more efficient, they are trying to maintain their profits — but they’re also at the same time trying to make sure that they are utilizing the lines that will allow them the highest profits,” Griggs said.
Yet, over time, generics have saved the industry and consumers billions of dollars, the Generic Pharmaceutical Association said.
“Generic medicines are a critical part of systemwide efforts to hold down health care costs,” Ralph G. Neas, president and CEO of the association, said in a written statement. Citing a study by IMS Institute for Healthcare Informatics, Neas said generics saved $209 billion in 2012, $239 billion 2013 and more than $1.46 trillion over the last decade.
Transgender medicine is a concept that is just now taking shape.
Massachusetts is drafting rules that will define the transgender services insurers will be required to cover. The Association of American Medical Colleges (AAMC) has just released guidance on training doctors to treat lesbian, gay, transgender and gender nonconforming patients. And Boston University Medical School has what Dr. Joshua Safer, a professor there, says is the nation’s first transgender medicine curriculum focused on the biology of gender identity.
Like I said: brand new stuff. But what do all these new rules mean for the doctor or nurse, in an examination room, who meets their first transgender or gender-fluid patient?
Here’s some advice from Dr. Safer, associate professor of medicine at Boston University Medical School, and Dr. Jennifer Potter, associate professor of medicine at Harvard Medical School. (Dr. Potter is a co-author of the AAMC guidelines.)
1) When greeting a new patient, or one you haven’t seen for some time, you cannot assume anything about their gender identity based on the masculinity or femininity of their appearance or the timbre of their voice. To avoid making mistakes, ask each new patient how they identify, what name they prefer to be called and what pronouns they want you to use. Note: Pronouns may be male (he), female (she), they or another gender-neutral option.
2) Consider collecting information about gender identity when you register patients, when they call to book an appointment and when they check in for a visit. This will help you identify patients and let them know they are welcome before you meet. Be sure to train office staff to demonstrate openness and respect. You can review sample registration questions here.
3) Apologize promptly if you make a mistake that causes offense to a patient. Many of us will use the wrong pronoun, for example. Or your office staff may call George into the examination room, even though George is now Georgina and presents as a woman. Transmen still need pap smears but may feel out of place in an OB/GYN office waiting room.
If your patient is offended, your apology can be a healing experience for a person who has predominantly encountered insensitive providers in the past.
4) Having such conversations and treating transgender patients or patients who do not identify as male or female may be uncomfortable for you. That is a common reaction. We all feel uncomfortable when venturing into unfamiliar territory for the first time. Use each encounter as an opportunity for personal and professional growth.
5) Always screen for gender dysphoria, but be aware that many people on the transgender spectrum have a positive self-identity and do not seek or need psychological support. However, the experience of discrimination, which unfortunately remains all too common, especially for individuals who transition after puberty and do not easily “pass,” can lead to gender dysphoria in some cases. You might suggest that your patient look for a counselor through the World Professional Association for Transgender Health (WPATH) or through the Gay and Lesbian Medical Association.
6) Some of you may wonder if you should recommend counseling instead of helping your patient change their body to fit their gender. A growing body of research says no. Your patient’s gender identity is rooted in biology. It is not a psychological choice. We don’t understand why there is a disconnect between gender identity and your patient’s body parts, but more and more research shows improvements in the mental well being of transgender individuals who change their external appearance to match their feelings inside.Living Transgender
WBUR reporter Martha Bebinger explores challenges facing transgender teenagers through the story of Nate, a 16-year-old transgender male.
- Part 1: Battling Perceptions And Pronouns
- Part 2: Nate Finds Acceptance At His School
- Part 3: Uncertainty Surrounds Medical Treatments For Transgender Youth
- Frequently Asked Questions, Resources
- Live Chat Transcript: Answers To Your Questions On Transgender Issues
7) You may also have questions about whether transgender identification is just a phase. Again, the latest research, while limited, says no, except in the case of prepubescent children. Consensus among doctors who treat transgender patients is that gender identity is established and does not change after puberty. If a child who was identified at birth as a boy switches genders during or after puberty, the new gender identity is generally fixed. This is true for adults as well.
The challenge, for children, is when to begin hormone blockers that will buy the child and their family some time before they must decide which gender to proceed with in puberty. You may want to refer a transgender or gender nonconforming child to a clinic that specializes in this care.
8) Be aware that some people on the transgender spectrum do not choose to alter their physical presentation to match their gender identity. Others may use or be interested in non-medical changes (e.g., breast binding, genital tucking, silicone injections), medical (cross-sex hormones) or surgical interventions. Be sure to evaluate each patient as an individual, by asking what they have done so far and/or what they are interested in doing in the future.
9) Your role in initiating cross-hormone therapy for adults can be pretty straightforward. A number of resources are available to guide such care and offer recommendations regarding clinical monitoring for patients on hormones.
10) Refrain from voyeuristic and intrusive genital examinations if not relevant to the patient’s presenting concerns. When such an exam is necessary, be sensitive to the fact that some people on the transgender spectrum may be uncomfortable having parts of their body examined that do not match their gender identity. Ask what words they prefer to reference body parts (e.g., gender-neutral terms such as pelvic opening as opposed to vagina) and be sure to explain what the exam entails, why you want to do it, and to obtain permission before proceeding.
11) Don’t forget about important prevention and health promotion. Patients on the transgender spectrum should have screening done as appropriate to the anatomy that is present (e.g., a transgender man with a cervix should have Pap tests). Vaccinations should be done as recommended by the ACIP. Just like anybody else, transgender individuals may have any sexual orientation and engage in diverse sexual behaviors that may change over time. Always ask and provide screening for sexually transmitted infections and contraception as needed.
By Alvin Tran
Marriage is hard even in the best of circumstances. But new research suggests that if things are particularly hard, the stress can take a toll on your heart — especially if you’re older and female.
In a new study published this week in the Journal of Health and Social Behavior, researchers found that older couples in bad marriages have a higher risk for heart disease compared to those in good marriages. This link between the quality of a marriage and the risk of heart-related problems, such as high blood pressure, is even more pronounced among female spouses.
“The strain and stress from the marital relationship has a strong negative effect on people’s heart,” said Hui Liu, and an associate professor of sociology at Michigan State University and the study’s lead author. “If the marriage is very stressful, it’s really hard on your heart.”
Liu, along with co-author Linda Waite of the University of Chicago, analyzed data from an ongoing nationally representative project that followed nearly 1,200 older men and women, ages 57 to 85, for a period of five years.
After comparing participants at the beginning of the study to the end of the five-year follow-up period, they found a significant link between an increase in negative marital quality with higher risk of hypertension among women. Not-so-hot marriages were marked by less spousal support and with husbands and wives spending less time with each other.
“The effect on marriage quality on cardiovascular risk is stronger for women than for men. It also becomes stronger as people get older,” Liu said during an interview. “We think marriage is one of the social factors that may affect the risk of cardiovascular disease.”
High blood pressure and rapid heart rate were among many factors the researchers used to assess the risk for heart disease.
“Even among those very old people who have been married for many, many years, we still see the effects of negative marriage quality,” Liu said. She suggested that improvements to a long-married couple’s relationship might offer a boost to the health of their hearts.
From the news release:
The findings suggest the need for marriage counseling and programs aimed at promoting marital quality and well-being for couples into their 70s and 80s, said…Liu
“Marriage counseling is focused largely on younger couples,” said Liu… “But these results show that marital quality is just as important at older ages, even when the couple has been married 40 or 50 years.”