Blaming Obamacare is the wrong diagnosis

The Wall Street Journal began the week by publishing a provocative essay in which a young man suggested Obamacare kept his mother from getting appropriate medicine for her cancer. The writer crafted a poignant story about his mother, who sounds like a good person with a bad disease.

Mainstream media buzzes with these types of stories. The Obamacare-is-the-problem narrative fits quite well on conservative news outlets.

The problem, as it so often is, is in the details.

The story here begins with a familiar first chapter: the writer’s mother had good insurance coverage but then it was cancelled. Next came her struggle to find a new policy on the federal exchange. The cancer patient ultimately learned that Humana would no longer cover her twice-monthly injections, and this left her with $14,000 in medical bills just two months into 2014.

I’m not sure what it was about this essay that stirred my journalistic self. Maybe it was the writer’s overuse of hyperbole (Procrustes, really?). Or that I expected more from the WSJ. Or that I’m trained to diagnose problems correctly, and blaming Obamacare for everything only delays fixing the real problems with American healthcare.

Though this case involves a specific drug for a rare cancer, the larger story centers on value, and evidence, and who pays for convenience, and this: why does an old drug cost so much?

A good place to start is to ask why Humana would deny coverage for this woman’s cancer drug?

The debate centers on the Novartis drug octreotide (Sandostatin). Given by injection, it is used to control symptoms caused by excess (tumor) secretion of the hormone serotonin, such as fatigue, nausea and gastrointestinal dysfunction. It is not felt to be a disease modifying agent.

Here are some of the pertinent facts:

The writer’s mother has a rare form of cancer called carcinoid. It’s not a well-understood disease and doctors disagree about its treatments. The rarity of the disease makes it hard to study outcomes.

Octreotide comes in two forms—a short-acting version that must be taken daily and a long-acting form that is taken every two weeks. The essayist made it clear that his mother was taking the long-acting version—which is expensive but convenient. He also correctly said that the drug was used for symptom control rather than control of the cancer itself.

A literature search led me to comparative studies between the two forms of the drug. There were no significant differences in efficacy or safety. The National Cancer Institute called the long-acting version of Sandostatin a “patient favorable formulation.”

Discovering these facts (dubious evidence for benefit and the presence of a less expensive alternative) allows one to see the problem from others’ perspectives.

One view is that of Humana: Is it wrong that third-party payers scrutinize the evidence for benefit before enriching the Novartis’s of the world? It is about value. If a short-acting version of the drug is equally effective, who should we ask to pay for the convenience? I know; writing that sounds awful, but the simple fact is that a decision on the cost of convenience has to be made–by someone.

(I called two pharmacies and learned that long-acting octreotide is ten times more expensive than the short-acting version. Also, the short-acting version can be given IV or SQ, which means a patient on the short-acting drug need not endure painful daily IM shots in the backside.)

Another perspective is that of the healthcare system as a whole. Why does long-acting octreotide cost so much? From my smartphone, I learned that the long-acting version is the exact same drug coated with a common polymer. In other words, it’s the same drug reformulated in a different package. Yes, it is surely a more convenient delivery system, but it is also one that allows Novartis to keep charging as if it’s a novel brand-name drug.

Now it’s time to look inward at ourselves—as Americans. As this LA Times reaction piece points out, the biggest misconception of Obamacare is that it is government controlled healthcare. It is not. Obamacare purposefully left intact the power of for-profit third-party payers and drug companies. That’s because Americans could not stomach the idea of having a single-payer government-run system.

You see what happens. For-profit third-party payers are not going to pay ten-fold more for merely convenient drugs. And drug companies will keep reformulating old drugs to maintain their profit streams. They aren’t baddies; they are just working within the American system. They are responding to the pressures we put on them. The cardiology analogy here is with the novel anticoagulant drugs, such as dabigatran, rivaroxaban and apixaban. I used to think insurance companies were wrong to deny coverage of these drugs. But then I looked at the evidence and found these drugs perform 99% the same as warfarin–a drug that costs pennies.

I’m hardly a policy guru but I am smart enough to know that what ails the American healthcare system is much more than a convoluted insurance reform act.

The first and most fundamental step in making a patient well is seeing and addressing the real problem.

JMM

Comments

  1. says

    Obamacare is certainly not the cause of the woman’s cancer, and the story may be less than a direct example as to how Obamacare will cause deaths, but it will. Anytime you require anyone to buy anything, especially insurance, you are taking life determining choices from patients. Now, they are not simply dying. They are dying powerlessly as the choices they may have had in terms of locating another physician or treatment strategy are limited.
    In some states as a direct result of Obamacare, specialist physicians are buying frozen yogurt franchises and getting out of the practice of government regulated medicine entirely. Fewer specialists will diminish the chances of my patients locating and getting in to see the right specialist. We could have improved access to health care in the US. We did not need a government regime that has a track record of doing nothing well, to trash our entire medical system.

  2. LK says

    Dr. John,
    Not sure I followed this statement: Is the short term a daily needle injection or is the long term solution a daily needle injection?

    (I called two pharmacies and learned that long-acting octreotide is ten times more expensive than the short-acting version. Also, the short-acting version can be given IV or SQ, which means a patient on the short-acting drug need not endure painful daily IM shots in the backside.)

    Please clarify. thank you

    • says

      Sorry…brevity and clarity oppose each other. IM injections are intra-muscular. They hurt. It would be lousy to have to take one of these each day. IV injections are not painful once a line is established–many cancer patients have semi-permanent IV lines. SQ (sub-cutaneous) injections are just under the skin, like insulin shots. Though they are still injections, they are not like the IM zingers.

      • tina abell says

        ……..and many cancer patients lose their muscle….so IM injections could be a real nightmare….

      • Karen Motylewski says

        Unfortunately Dr. Mandrola’s arguments, while cogent and timely, don’t address some additional key problems. Yes, pharmaceutical companies are profit-driven and we are all ill-served by the FDA approval process, with its flaws and expense. On the other hand, daily injections (vs. more extended intervals), putting aside other objections noted above) impose hardships and attendant expenses (travel, lost work time, etc.) on patients and caretakers. There are many factors to be taken into account in treatment decisions, and we are, as individuals and a nation, fixated on simple, universal solutions. This is a subject for broad professional and patient debate, unlikely to happen in our current educational, philosophical, and educational climate.

        • David Karpf says

          Karen,

          I believe his point (accurately) points out that while Sandostatin LAR has the convenience of extended dosing, it must be administered as a gluteal IM injection (e.g., in the butt). In contrast, the original form of Sandostatin (which is much less expensive), while given more frequently (which is less convenient), can be administered subcutaneously, which is not only a LOT less painful than IM, but can also be self administered by most patients. In fact, all of my acromegalic patients on octreotide (Sandostatin) give themselves their injections. So there’s not necessarily (or usually) any travel expense or hassle involved.

          The author is correct that this an Insurance Co. issue, as opposed to an ACA (“Obamacare”) issue. I have patients with policies that have low co-pays for Sandostatin LAR, and others with policies that push patients towards Sandostatin by having HUGE co-pays. I suspect that under ACA, as prior to ACA, she could have chosen a somewhat more costly plan that would cover the Sandostatin LAR. But it is pure right-wing hysteria to blame this on the ACA.

      • Doc C. says

        Sandostatin is usually given once a month, at most weekly. It is not a once a day IM injections. So the convience factor is twice a day SQ injections versus a usually every 3 to 4 weeks IM injection. That being said, the 10 fold cost difference has to be questioned.

        I had a patient who preferred short-term octreotide over the LAR form, and go figure, her insurance would not cover the former!

  3. jane says

    I completely disagree with the Obamacare approach of compelling everyone to buy a very expensive product from a for-profit corporation; it’s a vast transfer of wealth from the working class to the wealthy. However, the essay you link to is both disingenuous (the author does seem to explicitly claim the drug is lifesaving) and deeply selfish. It’s nice that his mother could afford the gold-plated plan. (If it’s so generous, why did it not meet the minimum Obamacare requirements? Could it be that the company voluntarily cancelled the policy to get rid of costly patients?) But he does not seem to think or care about what happened to people who got expensive cancers and couldn’t afford that plan.

    • David Karpf says

      Jane,

      Your entire premise is not fact-based. I helped a friend obtain insurance through the ACA, and she was able to get a terrific policy (better than my employer-provided policy) for a bit less than $39/month. Sure, if she made $50K per year instead of $17K per year her out of pocket would have been more, but even the fully loaded cost of the less expensive plans are VERY competitive with pre-ACA plans.

  4. Joe says

    I read the WSJ essay, and was interested enough to read more about the family profiled. My take away was somewhat different that yours.

    The lady profiled in the story is the practice manager for her husband, who is a Family Practice MD in Virginia. They are well educated, well connected in the medical world, and are more familiar than most with the ins and outs of both the medical and insurance systems.

    If they can’t figure out how to obtain comparable coverage under the ACA, how are the rest of us supposed to stand a chance?

    I have personal experience with a mentally disabled relative who has been employed and covered by employer based insurance for 20 years. He doesn’t earn much to start with, but the law changed and his hours were cut below 30. You can guess the rest of the story. Even with substantial help from family, and qualifying for full subsidy, he hasn’t been able to obtain coverage via the exchanges. It IS a bureaucratic nightmare.

    Imagine his chances if he didn’t have someone willing to spend countless hours trying to help him navigate the system on his behalf.

    The ‘new’ system is just plain broken, as was the old system. Maybe we’ll look back one day and say it was all worth it, but I truly feel for those who have been caught in the crossfire. It’s easy to see why so many feel it isn’t fair.

  5. Paul says

    I consider myself lucky to have health insurance. It is not a right but a commodity like any other. As a consumer, I have choices to make and my lifestyle is a component of the cost of health insurance. Yes, some diseases seem random and unfair, but if I choose a lifestyle that negatively impacts my health why wouldn’t I expect to pay more for health insurance?
    The ACA has removed the blinders from consumers that would or could not appreciate the real cost of healthcare. Like almost everything else, the only way to decrease healthcare consumption is to pay “market price” for insurance. Individuals who manage their health can expect lower rates. Better health reduces the cost for all of us – including taxpayers.
    Hospitals and insurance have only been around for 100 years (modern healthcare for 50). The evolved from charity by religious groups. That is why so many hospitals retain monikers associated with saints. But charity cannot pay for modern healthcare.

  6. Varun Sharma says

    It is very disheartening to see such reflexive bias against the ACA. I agree that it is not the best solution, but it’s the law of the land and we have to try to make it work. If we try to sabotage it and hope it fails at every turn, it will fail. We need to give it a chance and see how it turns out. Our country will be in horrible shape if it does fail.

  7. David Hansen says

    The ACA was sold using lie upon lie, passed in a party line vote on Christmas eve so people would be preoccupied. Then the Senate deems it passed as a total replacement to a bill that was actually passed. Top it off with no one read it first. Even if it was a good idea, that is not right. If it was a private company that had misled its’ customers like that, there would be heads rolling.
    Dr. Ben Carson is supporting a much better plan if your primary interest is the health of the patients and their ability to make their own choices.

  8. Sue McNear says

    Freedom of speech is the law of the land also, and it has to be part and parcel of any policy/law that is passed in this country. To me that means that our representatives need to construct laws that will work despite the vigorous response from a free people that have the power to vote. We are so lucky to have this and we need to believe in its preservation and in its use. That being said, i am glad to see Dr. John M’s thoughtful response to the WSJ article. As we all need to be aware, nothing is simple and we need lots of input to figure things out and act in our own best interest.

    • says

      Sue,

      The “Law of the Land” doesn’t mean what it once did. With the capricious and unconstitutional way that Obama – an alleged constitutional lawyer – is arbitrarily amending the ACA law to suit his poll numbers I see no reason why anyone should accept the ACA – the law of the land – as a forgone conclusion. The next president can use “executive privilege” to undue ACA.

  9. Deb Cunningham says

    “The cardiology analogy here is with the novel anticoagulant drugs, such as dabigatran, rivaroxaban and apixaban. I used to think insurance companies were wrong to deny coverage of these drugs. But then I looked at the evidence and found these drugs perform 99% the same as warfarin–a drug that costs pennies.” You’re being disingenuous here in comparing costs of drugs only. What about the required monthly lab work and inconvenience, time, travel and expense of using warfarin?

    • gretta gribble says

      actually the cost is pretty similar (although not for capitated hmo’s, who do not pay additional for the lab services) when you add up the cost of the lab draws when on warfarin.

      and concerning the sandostatin – it is difficult to understand why the protests about daily sq injections. they can be self-administered. diabetics give themselves injections several times a day with less objection. infertility patients give themselves sq lupron. cancer patients give themselves sq neulasta, neupogen. convenience and cost are often trade-offs; as other writers have noted, the entire society needs to consider these issues.

      • Doc Cathy says

        Regarding Sandostatin:

        It is NOT just a matter of convenience. Prior to the availability of the LAR, I had patients, one in particular, who had frequent episodes of Carcinoid crisis requiring ER visits and sometimes admission where she required octreotide IV and other measures. She would try to avert the crisis herself by taking muliple injections of the short acting form (but thus using up a weeks supply in one day).
        In this particular patient – it is no longer an issues of convenience/cost analysis, but an issue of doing what is best to avert a life threatening situation (her “crisis” included extreme hypotention and laryngeal spasms)

        Howerver, as doctors we do need to be more cognizant of the cost of the drugs we write prescriptions for. The cost differential between the two formulations is substantial. One 30 mg LAR kit costs about 4,000 dollars! One box of 30 of 100 mcg ampules of Octreotide is about 200 to 400 dollars. Even if tid dosing was required – at the highest price range we are talking about 1,200 dollars versus 4,000 a month.
        We need to make sure there is a medical reason the latter is needed beyond convenience. In the patient above, there is, but not in everyone.

        The problem is the crazy prices for the LAR – which is just a modified version of the immediate form. The companies heavily market their LAR product. The same company that came up with Octreotide now has sales teams that make you feel like you are a bad doctor if you prescribe it and not the LAR ;)

  10. Mel; Farmer says

    When will we learn that Freedom is not free of consequences that may impact individual freedoms. When hospital emergency rooms are mandated to treat individuals who can afford but choose not have medical insurance, the cost of care for everyone else is imacted. When we adhere to the so-called free market philosophy that allows drug companies to charge exorbitant prices in America for certtain drugs that are sold elsewhere at bargain rate prices, we suffer the cosqunces. When an individual chooses to use a drug that costs 10 times more than a similar drug that provides the same or similar benefits, is it any wonder that insurance companies and/or their stock holders, you and me, do not want to foot the bill for the higher priced drug.

    The ACA is not perfect, but it is a good start to rectifying many longstanding problems in providing a pathway for Americans to enjoy the Freedom of healthcare for every individual.

    • VES MD says

      Risky to hold forth on drugs out of one’s specialty,. Wear-off of short acting agents commonly cause rebound. Those of us who have been around long enough have seen replacement of longer acting biologically more suitable formulations with cheaper drug dumping versions. I am a cardiologist and in my bisuiness short acting agents may be cheaper but hazardous.
      I agree with blaming Obamacare here.

  11. Sergio Pinski says

    Good piece of investigative reporting. The writer of the WSJ article exhibited bad faith by omitting the alternative of the short acting SQ version of the drug. WSJ has now the same level of credibility that Fox News.

  12. Maureen says

    I’m curious. If the premise is that this is not the fault of Obamacare per se, but rather of the greedy insurance industry, then why was the greedy insurer willing to pay for the more expensive injections previously, but not after she had insurance through the government exchange? (the article states Humana would no longer pay…)

    • David Karpf says

      Maureen,,

      There are different levels of health insurance coverage on the private market, and also under the ACA. Everything from HMO, to restricted PPO to unrestricted PPO, and from catastrophic coverage with high co-pays and high deductible to more expensive plans with low co-pays and low deductibles. Folks who don’t take a lot of meds can choose a lower cost plan that has a more restricted formulary with higher co-pays for off-formulary meds, whereas folks taking a lot of meds might prefer to choose a plan with a wider formulary coverage and lower co-pays for off-formulary drugs.

      What I’m saying is that she probably could have chosen a plan that had a lower co-pay for the sandostatin LAR than the plan she chose. This has been an issue for the 34 years i’ve been a physician – one patient will have coverage for a given a drug, and the next patient won’t. This is not something created by the ACA….

  13. Jeff says

    It’s a sad commentary when an article with Obamacare in the title gets five times as many comments as one with Atrial Fibrillation in the title – on the same electrophysiologist’s blog.

    And, such emotion!

    (I wonder what the response would have been with “Affordable Care Act” in the title.)