How the government bent the cost curve in the wrong direction


Category : Medical Rants

The NEJM carried this important article in June – Incentives for Drug Development — The Curious Case of Colchicine

The implications of market exclusivity for the public health can be substantial. After the FDA approved Colcrys, the manufacturer brought a lawsuit seeking to remove any other versions of colchicine from the market and raised the price by a factor of more than 50, from $0.09 per pill to $4.85 per pill.4 These increased prices directly affect the availability of the drug to patients with gout or FMF who have long been using colchicine safely in an evidence-based manner. Exclusivity can also affect health care delivery more broadly. According to the Centers for Medicare and Medicaid Services, state Medicaid programs filled about 100,000 prescriptions of colchicine in 2007 and paid approximately $1 million for the drug. Use of the new brand-name colchicine could add as much as $50 million per year to these insurance programs' budgets at a time when they are addressing the rising costs of health care by reducing some services or raising eligibility thresholds.

You really must read the entire article.  I suspect that you (like me) will have extreme outrage over this decision.  Let me repeat – 10 cents a pill increases to $5 per pill.  This is the same drug people.  This drug was old when I was a medical student in the early 70s.

The WSJ weighed in on Friday – FDA Warns Certain Gout-Drug Makers to Stop, And Soon

Colchicine has been a gout remedy so long that its use preceded the FDA, and so the several companies that made and sold it didn’t need agency approval to do so. But last year, a Philadelphia company called URL Pharma won FDA approval for its colchicine product, Colcrys, to treat acute gout pain.

How can we decrease medical costs when our protector agency – the FDA – makes such an inane decision?  One question – WHAT THE HELL ARE THEY THINKING?

Comments (3)

Its a free market and everybody is trying to grab more than their share – drug companies cheat like above  but they are not alone. Majority cardiologists do excessive caths; majority gastroenterologists do excessive scopes; majority pulmonologists order, read and interpret excessive PFTs, majority primary docs try to squeeze in one extra patient to provide maintenance care and if ill, divert them to ER/hospital. The examples are many and if all of us look inside ourselves, we know who is cheating (or gaming the system) and who is not. The other day an endocrinologist stopped me to inform me of how my tapering of steoids in a (now extubated) patient messed up his insulin drip. If the system was all transparent, there is no need for an endocrinology consult in most in-patient situations…….but then as someone wisely said, a dollar saved in health care is a dollars worth of income for somebody.

There are a number of things that have changed drastically in ICU medicine sinceI began practicing 30 years ago. One of them is the dependence on consultants. USed to be you had the ICU doc who made most of the decisions and had to interpret labs, handle meds, decide on what test to get and make most crucial decisions. Yu got consults, surgeons in case surgery was an option, subspecialists for difficult diagnostic issues or procedures but pretty much they had an ancillary role. You were responsible.
Now its a completely different game. Everybody gets into the act as you noted. The best way to get your suggestion implemented is to be the first person or last person of the day to enter something into the chart. Everyone  is responsible. Except fo course when everyone is responsible, no one is.     

Cory – you are so right about the first or last person of the day. I get this everyday having moved from a closed ICU in training to open ICU in practice – its not that open ICUs are worse in any way.
I am sorry that I digressed from the topic which was raised but I just feel that as physicians, we easily get sucked into the blame game – at some point, we need to look into ourselves too; I am not saying the doctors do not deserve all the income (probably they deserve more) but currently, as we all know, the focus and manner which money is circulated is a problem.
As an example, it takes me a total of 5 minutes to bronch (supposedly called a "clean out" bronch) an intubated patient and I have tried to resist doing so without any real indication (I see that happening every day being performed by my colleagues – surgeons, pulmonologist, intensivist alike) – I am looked at by other people (nurses, RTs, other docs) as being refractory  to their suggestions.  I know it is not their fault to ask for one as they have been trained/taught thinking that a clean out bronch is the answer. My question is – who is responsible for that training or thought process or culture? I think its US – the doctors who do such procedures and teachers who teach such procedures (5 minutes of procedure makes 200 dollars for the physician and more than 2K fo the system – equipment, scope, excessive antibiotics etc). I know somebody will suggest to kill the money driven procedures which has already happened – a bronch in non-intubated patient pays the same, takes more time, usually has better indications but is unattractive to the pulmonologist as it generates 200 dollars for 1 hour. And this kind of behaviour is not lmited to procedural specialities alone….primary docs have heir way of finding things – excessive skin biopsies, stress tests, vascular studies, multiple office visits etc.
For me, a clean out bronch does not pass the MOTHER TEST (what will I want done to my mother or family member if they were the patient). I think this was the best thing taught to me by my mentors. I hope I dont lose this skill in our current complex system…..I think we owe it to our patients.
I also think the audience in this blog are a select group of people who think alike broadly ..but they are in minority in the real world.

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